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Investigations in the NHS

896 investigations 8078 recommendations 11 regions

Independent investigation reports and reviews commissioned by government or NHS bodies. Includes mental health homicide investigations, major maternity reviews, patient safety reviews, and other independent investigations into healthcare failures.

Coverage

By region & key findings

Investigations by region

Key findings

896 independent health investigations across 11 regions, producing 8,078 recommendations. 76% of investigations have extracted recommendations. 683 investigations have recommendations tracked.

Investigations

Click an entry for full report & recommendations
London
Independent investigation: John Trinder, Peckham (1995)
Schizophrenic fatally and repeatedly stabs victim. Ind Inq 1999, previous history of stabbings
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: John Uttley, Huddersfield (2017)
Paranoid schizophrenic fatally batters stepfather. Previous history of violence and serious mental illness. Convicted of murder
9 recommendations Report PDF
East of England
Independent investigation: John West, Sheringham Norfolk (2004)
Paranoid schizophrenic killed his father in law. Ind Inq 2008. Previous violence, released days earlier, warnings. Poor risk assessment. Poor team work.
-1 recommendations Report PDF
South East
Independent investigation: John Willdig, Southampton (2014)
Paranoid schizophrenic fatally stabs pensioner. MH history
13 recommendations Report PDF
South East
Independent investigation: John Williams, Camberley (2011)
Mentally ill man repeatedly and fatally stabs man
15 recommendations Report PDF
South West
Independent investigation: John Witts, Cinderford (1995)
Mentally ill man fatally stabs brother. Ind Inq 1997
-1 recommendations Report PDF
South East
Independent investigation: Jonathan Ellison, Brighton (2011)
Mental Health Patient fatally batters vulnerable man. Long Forensic history, D&A problems, PD
-1 recommendations Report PDF
South East
Independent investigation: Jonathan Newby, Oxford (1993)
Psychotic fatally attacked volunteer care worker. Ind Inq 1995, previously sectioned
5 recommendations Report PDF
North West
Independent investigation: Jonathan Palgrave, Preston (2018)
Paranoid schizophrenic fatally punches mentally-ill fellow resident
4 recommendations Report PDF
London
Independent investigation: Jonathan Zito, Finsbury Park (1992)
Paranoid Schizophrenic fatally stabs stranger in the eye.. Catalogue of MH Service errors, very critical inquiry 1994
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: Jordan Cooper, Washington (2011)
Mentally disordered man fatally stabs nephew
8 recommendations Report PDF
London
Independent investigation: Joseph Collins, Islington
Paranoid schizophrenic with history of serious assault, kills stepfather after ceasing taking medication. Ind Inq 1997 – Long history of MH problems & violence. Cf Kurter
4 recommendations Report PDF
South East
Independent investigation: Joseph Day, Folkestone (2001)
Schizophrenic (triggered or exacerbated by drug abuse) fatally stabbed another. Ind Inq 2004 found failures and errors. No Risk Ass. Team work poor
-1 recommendations Report PDF
South West
Independent investigation: Joseph Osmond, Salisbury (1997)
Mentally ill man fatally and repeatedly stabbed landlord. Ind Inq 1999. previously sectioned, then released before killing
-1 recommendations Report PDF
South West
Independent investigation: Joyce Lovell, Donhead St Mary, Wilts (2008)
Mentally ill man fatally batters mother. Poor practice found
13 recommendations Report PDF
South East
Independent investigation: Judith Kimber, Portsmouth (2004)
Paranoid Schizophrenic with history of violence fatally smothers mother
6 recommendations Report PDF
South East
Independent investigation: Julie Ann Wendel (Ms L), Netherfield, East Sussex (2002)
Long term MH patient strangled girlfriend. Indep Inq. Previous violence. 2005, Georgiou
9 recommendations Report PDF
Midlands
Independent investigation: Julie Clark, Hereford (2018)
Mentally ill man fatally and repeatedly stabs his mother. Trial of facts as Unfit to plead
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: Julie Davison, Whitby (2012)
Mentally ill man fatally stabs stranger. Ind Inq found failings in care
10 recommendations Report PDF
London
Independent investigation: Julie McKinley, Finsbury Park (2009)
Recent MH patient fatally strangles wife while children were sleeping. Long history of violence
12 recommendations Report PDF
North West
Independent investigation: Julie Owens, Liverpool (2018)
Mentally disordered man with schizophrenia fatally battered his mother. Admitted manslaughter – jailed for four and a half years
3 recommendations Report PDF
East of England
Independent investigation: June Jumaily, Letchworth (2009)
Mental health patient fatally stabs estranged wife in front of daughter. History of psychosis
9 recommendations Report PDF
South East
Independent investigation: Justin Skrebowski, Abingdon (2015)
Psychotic man fatally stabs stranger. Long history of MH problems & violence. Had prev made threats to kill
5 recommendations Report PDF
South West
Independent investigation: Kamil Ahmad, Bristol (2016)
Paranoid schizophrenic with history of violence fatally stabs and mutilates refugee. Previous Rampton patient – released by Tribunal day before
14 recommendations Report PDF
Midlands
Independent investigation: Karen Godden, Leicester (2007)
Paranoid Schizophrenic fatally stabbed neighbour with chisel. Ind Inq 2010 (2007/9113 Recently released from Psych hospital – stopped meds.)
6 recommendations Report PDF