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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
East of England
Independent investigation: Mandlemkosi Nelya (Mandla Leya), Cambridge (2006)
Conditionally released psychiatric patient batters friend and leaves him to freeze to death. Case F in Inq report. Verita 2010. History of psychotic illness & prev. violence.
6 recommendations Report PDF
East of England
Independent investigation: Marcus Witham, Colchester (2006)
MH patient (w PD and sub-stance abuse problems) fatally stabs partner. Case ‘E’ in Inq. Report
4 recommendations Report PDF
Midlands
Independent investigation: Margaret Casey, Edgbaston (2009)
Mentally ill woman bludgeons elderly mother to death. Lengthy MH history – not taking meds
4 recommendations Report PDF
Wales
Independent investigation: Margaret Ford, Templeton, Pembs (2009)
Paranoid Schizophrenic fatally and repeatedly stabs mother then cuts her throat. Long MH History – Family critical
4 recommendations Report PDF
South East
Independent investigation: Margaret HarrisSharon Harris, Hadlow, Kent (2018)
Paranoid schizophrenic fatally stabs neighbours. Under a CMHT at the time of the assault
5 recommendations Report PDF
Midlands
Independent investigation: Margaret McIntyre, Corby, Northants (2007)
Mentally ill man kills grandmother
6 recommendations Report PDF
South East
Independent investigation: Marie Harding, Worthing (2004)
Psychotic fatally stabs strangers (& 3 in London). Ind Inq 2009 Mother had been asking for MH help for him for months
7 recommendations Report PDF
South East
Independent investigation: Mark Austin, Aylesbury (2013)
Long Term MH patient fatally attacks man. Long MH history w violence – previous hospital order
2 recommendations Report PDF
North East and Yorkshire
Independent investigation: Mark Berry, Dewsbury (2005)
MH patient kills stepfather (provocation). Ind Inq (2005/2100) 2007
13 recommendations Report PDF
South East
Independent investigation: Mark Blackston, Northfleet, Kent
MH patient fatally stabbed victim. Ind Inq 2005. Previous violence, had warned she would kill s.o
10 recommendations Report PDF
London
Independent investigation: Mark Evans, Ilford (2005)
MH patients fatally strangled punched and kicked man and set fire to his body in wheelie bin. MH history (Ind Inq NHS 2010)
9 recommendations Report PDF
Scotland
Independent investigation: Mark Johnston, Dundee (2017)
Psychiatric patient fatally stabbed best friend 120 times two days after discharging himself from hospital. Transferred due to lack of beds & walked out
-1 recommendations Report PDF
London
Independent investigation: Mark Kent, Hayes (2007)
Paranoid schizophrenic fatally stabs friend. Ind Inq – ‘not sucessfully treated’ weeks before offence
14 recommendations Report PDF
London
Independent investigation: Mark Murphy, Streatham (2006)
Paranoid Schizophrenic fatally stabs stranger. Critical Inquiry, 2011
3 recommendations Report PDF
South West
Independent investigation: Mark Pinnell, Clevedon (2009)
MH patient fatally stabs aquaintance. MH history
12 recommendations Report PDF
South West
Independent investigation: Marta Elena Vento, Bournemouth (2020)
Paranoid schizophrenic fatally batters young hotel receptionist in extended and brutal assault. Recently released from prison – off meds – diminished responsibility
17 recommendations Report PDF
East of England
Independent investigation: Martin Cass, Ford End, Essex (1998)
MH patient fatally shot ex’s new partner, then shot himself. Ind Inq 2001
-1 recommendations Report PDF
London
Independent investigation: Martin Ellicot, Walthamstow (2006)
Homicide by homeless mentally ill. Indep Inq
5 recommendations Report PDF
East of England
Independent investigation: Mary Griffiths, Bury St (2009)
Deluded recent mental health patient kills woman with bolt gun
14 recommendations Report PDF
East of England
Independent investigation: Mary (Maisie) Dempsey, Harpenden (2005)
MH patient fatally stabs elderly neighbour 40 times. Substance abuse problems – Case B in Inquiry report. 2010, Verita.
4 recommendations Report PDF
London
Independent investigation: Mary Skerrit (81)Keith Fernandez, Stoke NewingtonPalmers Green
Schizophrenic stabbed partner 58 times and Gt Grandmother 130 times. Ind Inq 2010 had been released from hospital twice after psychosis improved
10 recommendations Report PDF
East of England
Independent investigation: Matthew Bowyer, Essex (1996)
MH patient sets mothers house alight and kills lodger. Ind Inq 1999 Herbert
-1 recommendations Report PDF
London
Independent investigation: Matthew Carter, Tooting (2006)
Paranoid Schizophrenic fatally kicked and stamped on stranger. V Critical Ind Inq. 2008. Family wanted him admitted – ceased meds. Prev. violence.Refused consent for release of medical records. Care too patient centred.
19 recommendations Report PDF
Midlands
Independent investigation: Matthew Lynch, Handsworth (2023)
Mentally disordered man repeatedly and fatally battered and stabbed man. Diminished responsibility – ‘indefinite’ hospital order
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: Maureen Rudland, Durham (2015)
Alzheimers patient with history of aggression pushes fellow resident who subsequently died
9 recommendations Report PDF