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The Royal College of Psychiatrists Improving the lives of people with mental illness

Reviews, Investigations and Inquiries

To contact the Psychiatrists' Support Service please telephone: 020 7245 0412  or e-mail:

If you're facing a review, investigation or inquiry, make sure you're:


  • Clear – Do you know what process you're facing?
  • Prepared – Are you ready for the process?
  • Supported - Have you spoken to a professional body for advice and to family/friends for support?


Remember, apologising isn't a sign of weakness or accepting blame. Showing regret and willingness to learn lessons is an appropriate professional reaction to an adverse event. If you're defensive, it could be wrongly interpreted.




Investigations are usually done locally by an investigator who is employed by the same organisation as the psychiatrist, team or service being investigated. As it is an internal process, timescales are short.


If there is a conduct or behaviour problem that could lead to a disciplinary process, then the issue will typically be investigated by a single investigator or panel. A panel is sometimes more appropriate when the adverse event is of clinical concern.


The Chair of the panel is usually a non-executive member of the trust board in the NHS. In independent sectors, there might be a non-clinician Chair. If the concern is about the clinical practice of a psychiatrist there should be a psychiatrist on the panel.




A review is conducted by a panel, which has at least one member from a professional body outside of the trust. There will also be a psychiatrist on the panel who should be an experienced senior clinician with appropriate speciality knowledge.


The process is longer than a review investigation because there are external professionals involved and the focus is on a service rather than an individual.




Formal inquiries are a response to serious events, such as an individual in contact with mental health services committing murder or negative publicity following an incident. Often chaired by a lawyer or judge, the panel membership is wider - including a psychiatrist, a nurse, a social worker and a lay representative(s).


More formal than a review or investigation, the process is long and detailed. Witnesses give evidence and their testimony could be recorded and transcribed. Usually, the employer sets up an investigation or review before the external inquiry from a primary care trust in the NHS.



Things to consider



If an adverse event has occurred, anticipate that a process of review/investigation/inquiry may take place. If you're told there will be a review, investigation or inquiry, respond by letter to your clinical or medical director. Seek advice from your medical defence organisation, and the British Medical Association if you’re a member.


If you’re contacted in advance, ask:


  • Is this a review, investigation or inquiry?
  • Who is on the panel?
  • What are the terms of reference?
  • What is the timescale?
  • Will I have to give oral or written evidence?
  • If I have to give oral evidence, can a colleague or professional adviser accompany me?
  • Will the process focus on learning lessons and improving services or will I be criticised?
  • How will the final report be produced?


Whether you're facing an investigation, review or inquiry, make sure you provide a transcript of what you said and what will be used to prepare the report. Ask whether you’ll get to see either the whole report or part of it without conclusions so there’s an opportunity for you to correct information.




  • If there has been an adverse event, seek professional advice and think about whether an investigation, review or formal inquiry is most likely to follow
  • Set up a Serious Incident Review with the clinical team and go over:

    • what happened before the adverse event
    • the event itself
    • the response to the event
  • Support your staff and clinical team - but also arrange your own support network

  • Read all documentation relating to the case

  • Don't appear before an investigator, review panel or inquiry without preparing for the questions you're likely to be asked

  • If you give oral evidence, bring a professional supporter/adviser with you
  • You can always take a break from the interview process if needed




Reviews, investigations and inquiries can be extremely stressful and impact both your professional and personal life. Secure a professional support network - a colleague you can trust or a mentor. Psychiatrists can get mentors through local contacts, the local deanery or College divisions.


Take care of yourself. If your mental or physical health is being affected, seek support.


For further help and support, see our resources page on contacting the British Medical Association and Medical Defence organisations.



This document focuses primarily on the consultant psychiatrist. It may be helpful for trainees or non-training grade psychiatrists if brought into a review, investigation or inquiry, but for them the first line of support and advice should be from their consultant. The information should be used as a guide only and is not a substitute for professional advice.


© Royal College of Psychiatrists 2016

If you require advice and support about a particular issue then please contact the Psychiatrists' Support Service at the Royal College of Psychiatrists on 0207 245 0412 or email

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