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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
North East and Yorkshire
Independent investigation: Karen Leonard, Middlesbrough (2009)
Psychiatric patient fatally battered strangled and stabbed partner. Prev. told nurses of fears of violent relapse
-1 recommendations Report PDF
Wales
Independent investigation: Karen Welsh, Cardiff (2010)
Paranoid Schizophrenic fatally beat and strangled nurse who befriended him. Sought help before killing
14 recommendations Report PDF
Wales
Independent investigation: Karina Menzies, Cardiff (2012)
Paranoid schizophrenic kills disabled young mother and injures 17 others. Long MH history, off meds, nearly killed 13 others including children
15 recommendations Report PDF
London
Independent investigation: Kasey Gordon, Tottenham (2011)
Paranoid Schizophrenic fatally stabs schoolboy. Long MH history – previous warnings about knives
13 recommendations Report PDF
East of England
Independent investigation: Kathleen Bainbridge, Dunstable, Beds (2007)
Mentally ill man fatally stabs care assistant and attempts to kill another. Unfit to plead. Herts patient
6 recommendations Report PDF
South East
Independent investigation: Katie Kazmi, Reading (1999)
Schizophrenic ex Broadmoor inmate fatally stabs stranger 77 times. Ind Inq 2002. ‘damning indictment of incomptence and complacency
-1 recommendations Report PDF
East of England
Independent investigation: Katie Locke, Waltham Cross (2015)
Recent Psychiatric patient strangles woman and abuses her body. Had made prev. threats to kill, recently released from psych.hospital
4 recommendations Report PDF
East of England
Independent investigation: Katy Sprague, Cambridge (2019)
Mentally disordered man fatally strangles fellow resident in supported accommodation. Convicted of murder – had asked to be sectioned day before without success.
6 recommendations Report PDF
South East
Independent investigation: Keith Bevis, Portsmouth (2013)
Paranoid schizophrenic fatally stabs man 38 times. 24 year history of mental illness – ‘revolving door’ patient
11 recommendations Report PDF
London
Independent investigation: Keith Drummond, Perivale (2010)
Paranoid schizophrenic fatally stabbed and battered his father. Long MH history, not taking meds, mother tried to get help in vain
3 recommendations Report PDF
North East and Yorkshire
Independent investigation: Keith Robinson, Scartho (2017)
Mentally ill and delusional woman starts fire and kills partner. Many previous warnings by family
5 recommendations Report PDF
North East and Yorkshire
Independent investigation: Kelly Franklin, Hartlepool (2018)
Mentally disordered man repeatedly and fatally stabs ex-partner. Considered so risky female staff told not to see him alone – convicted of murder
5 recommendations Report PDF
Wales
Independent investigation: Kenneth Auger, Merthyr Tydfil (2008)
Mentally ill man (bipolar) kills neighbour with a hammer. Repeatedly asked MH services for help – ignored
18 recommendations Report PDF
North East and Yorkshire
Independent investigation: Kenneth Godward (77)Roger Lamb, St James’ Hospital, Leeds (2015)
Schizophrenic in acute hospital fatally assaults two fellow patients. Off meds – Long MH history
21 recommendations Report PDF
North West
Independent investigation: Kenneth Horrocks, Bolton (1996)
Paranoid Schizophrenic suffocates elderly neighbour. Ind Inq 1998 – care and comms failures
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: Kenneth Light, Leeds (2005)
Paranoid Schizophrenic fatally stabs father 120 times. Ind Inq (2005/ 2579) 2009. Long MH history – family concerns
3 recommendations Report PDF
North East and Yorkshire
Independent investigation: Kevin Hodkinson, Sheffield (2022)
Paranoid schizophrenic pushes stranger angler into lake and drowns him. Diminished responsibility – Sec 37/41
4 recommendations Report PDF
South East
Independent investigation: Keziah Flux Edmonds, East Cowes, IoW (2016)
Depressed man fatally drowns daughter and takes his own life. MH history
12 recommendations Report PDF
East of England
Independent investigation: Khabi AbreyUnborn Baby, Westcliff (2016)
Mentally ill man sets fire in block of flats killing neighbour and her unborn baby
5 recommendations Report PDF
Northern Ireland
Independent investigation: Kieran Hegarty, Strabane (1994)
MH patient abducted and killed schoolboy
-1 recommendations Report PDF
London
Independent investigation: Kyle Maher, Tooting (2017)
Mentally ill man repeatedly and fatally stabs flatmate. Convicted of Manslaughter by diminished responsibility
10 recommendations Report PDF
London
Independent investigation: Lance Scott Walker, Hayes (2016)
Paranoid schizophrenic fatally stabs vulnerable teenager in hostel. Was due for MH assessment three days later
26 recommendations Report PDF
South East
Independent investigation: Laura Sturla, Gillingham (2003)
Mentally ill man fatally injects former patient with heroin
-1 recommendations Report PDF
Northern Ireland
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005)
MH homicide of daughter and herself. Ind Inq found catalogue of errors and missing notes
36 recommendations Report PDF
North West
Independent investigation: Leanne Unsworth, Burnley (2019)
Paranoid schizophrenic fatally batters woman. Diminished responsibility
10 recommendations Report PDF