Starting on 29 September 2017, the disappearance and death of 25-year-old Anne Faber dominated the news in the Dutch media for weeks on end. The societal unrest built up in Den Dolder after the Public Prosecutor’s Office announced on 12 October that Anne had been raped and killed by one of the residents of a local forensic psychiatric clinic. The Dutch Safety Board investigated how forensic care prepares perpetrators of serious violent and sex crimes for their return to society and how local authorities are involved in this return.

Investigation publication

Forensic care and security - Lessons from the case Michael P

The Dutch forensic care system

Forensic care is mental health care that is part of a judicial sentence or measure. Its most important goal is to prevent repeat offences. Because forensic care has two components – care and safety – that can each vary in intensity, the forensic care system has several modalities. The most well-known is tbs, a form of psychiatric detention with involuntary treatment, and distinguishes itself from the other types because a psychiatric detention measure can be extended as long as experts consider the concerned person as too dangerous to be released. The other modalities, which do not have this option, fall under the collective term ‘other forensic care’ (OFZ).

In 2017 the person that killed Anne Faber was in Den Dolder under treatment at a Forensic psychiatric unit (FPA), one such type of other forensic care. The Safety Board examined this case to get a picture of how other forensic care works in practice.


The Safety Board has observed deficiencies in the way perpetrators of serious violent and sex crimes are prepared for a safe and responsible return from other forensic care back to society. To eliminate these deficiencies, improvements are needed in risk assessment, division of responsibilities and information exchange.

The sanctions and protection legislation that is now being prepared can contribute to this, but does not have enough reach to eliminate the deficiencies observed by the Board.

The Board expects all the involved parties (the Judicial facilities service (Dienst Justitiële Inrichtingen), forensic care facilities, the Public Prosecutor’s Office, Probation Service, municipalities and the police) to jointly use the findings and conclusions from this report to accomplish the required turnaround in thinking and acting. It is up to the Minister for Legal Protection to take the lead in accomplishing an overarching and joint approach, and to ensure the necessary prerequisites.

The Safety Board recommends the following to the Minister for Legal Protection:

Enhance the focus on risk of repeat offences

1. Enhance the focus on public safety in the treatment of high-risk patients in other forensic care.

Align responsibilities with common goal

2. Reassess the tasks and responsibilities of all the involved parties for their contribution to the common goal: the safe and responsible return process from other forensic care of criminals with a high risk of reoffending. Adjust these tasks and responsibilities as needed.

3. Do not grant freedoms to criminals at a high risk of reoffending without providing adequate supervision. To this end, provide clarity about the interpretation and application of articles 15.5 and 43.3 of the Custodial Institutions Act (Penitentiaire beginselenwet).

Improve the conveyance of information

4. Improve the continuity of care and safety by transferring all the information relevant for meeting the responsibility of the receiving party before relocating detainees from a PI to other forensic care. Risk taxations, court reports, behavioural reports and medication prescriptions of the person concerned should be considered in any event. A precondition for the voluntary relocation of the detainee to a different regime and when transitioning from detention to conditional release (v.i.) should be his agreement to the transfer of all relevant information.

5. Strengthen the information position of municipalities by modifying the BIJ-regulation and improving its implementation.

6. Legally regulate the exchange of data between municipalities, judicial institutions, forensic institutions and other relevant parties to give municipalities better control of criminals’ resocialization risks.



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