The Three Inquiries: The Kerr/Haslam Inquiry

Terms of reference: To investigate how the NHS handled allegations about the performance and conduct of William Kerr and Michael Haslam.

Chair: Nigel Pleming QC

Panel: Ruth Lesirge and Ros Alstead


Inquiry (along with two others) announced on 13 July 2001

Hearings: commenced 29 April 2003, evidence heard from 30 April 2003 to 25 July 2003 (27 sitting days). Inquiry formally closed on 31 July 2003

Report: published 15 July 2004

Link to download report:

Description of the events which caused the public concern: In 2000, William Kerr was convicted of one count of indecent assault and in 2003, Michael Haslam was convicted of four counts of indecent assault. Both worked as consultant psychiatrists at the same hospital in York, and the victims were vulnerable psychiatric patients.


General Medical Council v Kerr [2002] EWHC 2338 (Admin)
Haslam v Times Newspapers Ltd (unrep., QBD, 15 November 2001)

Summary of reportís recommendations:

  • Improvements to the process of taking up references for job applicants.
  • Procedures and policies to ensure that all NHS organisations are aware of the therapies being undertaken by all staff, and approval required for new/unorthodox treatments.
  • The NHS should reconsider whether or not statutory regulation should be extended to cover hypnotherapy.
  • Policies to guide NHS managers in their handling of allegations or disclosure of sexualised behaviour and to reduce the likelihood of it occurring.
  • Independent advice and advocacy services should be funded to support complainants, and protocols to ensure complainants are treated with care, consideration and integrity.
  • Wider changes to complaints processes in NHS, including whistleblowing procedures and recording of complaints and improved training of all staff and particularly those who handle complaints.
  • Chaperones should be used in medical procedures that require benzodiazepines to be given intravenously.
  • Guidance, advice and instruction (preferably in consultation with the professional regulatory bodies and healthcare colleges) as to the meaning and limitations of patient confidentiality in mental health settings.
  • Expert consideration of the boundaries need to be set between patients and mental health staff who have been in long term therapeutic relationships, and how those boundaries are to be respected.
  • Guidance should for medical professionals addressing conduct which will not be tolerated and which is likely to lead to disciplinary action.
  • Mental health services should provide routine information to patients attending appointments on what to expect from a consultation with a mental health professional.
  • Review of current records management practice in the NHS.
  • Improvements to the working methods of Patient Advice and Liaison Services (PALS).
  • Centralised database of performance of individual doctors.
  • Information sharing duties between the Department of Health and regulatory bodies.
  • In relation to private inquiries for witnesses who make statements, and/or who give oral evidence, legal safeguards should be introduced to grant them immunity from action in relation to their evidence (whether fact or opinion), in the absence of malice.
  • If not already appointed, a multidisciplinary committee should be established to collate, consider and report on the recommendations made in this Report, the Shipman Report, the Neale Report, the Ayling Report and the Peter Green Report, insofar as those Reports and the recommendations made in them relate to the common theme of handling concerns and complaints, and to patient protection.