All Trusts delivering secondary mental health services must have a system in place
for examining what are called serious and untoward incidents [ SUI's ] .... ' e.g. suicides, violence and 'near misses'
- and example of the latter, would be discharging some one
who had previously been verbally and threateningly abusive to a family carer,
being discharged, or allowed out on leave, without the carer being fore-warned and advised. Usually such SUI incidents are reviewed every month
- but the people doing it are rarely disclosed
nor are the incidents being reviewed ever sufficiently detailed.
However where a carer might have been or be involved, carers have a right
to be given the opportunity to ask, to be informed, and to put in and have recorded their views on the incident.
Where there has been a homicide when the perpetrator was
in some way in the care of the secondary specialist service,
a mandatory External Independent Inquiry must take place,
preceded by an internal inquiry very soon after the tragedy
to put in place the changes, found by the internal inquiry, to be immediately necessary for the service.