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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
South West
Independent investigation: Rosemary Armstrong, Bournemouth (2010)
Mentally ill woman fatally stabs mother.. Later tried tosue MH trustfor poor care
-1 recommendations Report PDF
East of England
Independent investigation: Rosemary Neale, Colchester (1999)
MH homicide of mother. Ind Inq 2002
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: Rosie Palmer, Hartlepool (1994)
MH patient abused, killed and kept 3 year old victims body in plastic bag at home.. Ind Inq 1996
-1 recommendations Report PDF
London
Independent investigation: Roy Barber, Chiswick (2006)
Schizophrenic fatally and repeatedly stabs care home resident. MH history
3 recommendations Report PDF
South West
Independent investigation: Roy Warnes, Plymouth (2002)
Psychiatric patient kills neighbour. Ind Inq 2004 found failings. Previous Inpatient
1 recommendation Report PDF
East of England
Independent investigation: Russell Capon, Ipswich (2013)
Schizophrenic repeatedly and fatally stabs childhood friend. History of mental illness
6 recommendations Report PDF
East of England
Independent investigation: Ruth Jacobs, Needham Market (2011)
Merntally ill man drowns disabled wife. Sentenced Sec 37 MHA – no restriction
5 recommendations Report PDF
North West
Independent investigation: Ryan Livesey, Blackburn (2011)
Unmedicated paranoid schizophrenic punches and kicks friend to death. Extensive drug and MH history
3 recommendations Report PDF
North West
Independent investigation: Ryan Lowry, Manchester (2020)
Paranoid schizophrenic fatally and repeatedly attacks his cousin. Long MH history – off meds, inadequate risk assessment
5 recommendations Report PDF
South West
Independent investigation: Ryan Merna, Poole
Mentally ill man repeatedly & fatally stabs vulnerable former friend. Previous warnings of violence
11 recommendations Report PDF
East of England
Independent investigation: Ryan Walsh, Cheshunt (2008)
Mental health patient fatally stabs boyfriend. MH history w violence – inquiry found many failings in care. Ind inq. 2013 Iodem
-1 recommendations Report PDF
London
Independent investigation: Sally Hodkin, Bexley (2011)
Released restricted MH patient fatally stabs stranger. Had previously killed mother in 2005
21 recommendations Report PDF
South West
Independent investigation: Sally Poynton, Crowlas (2021)
Psychotic man repeatedly and fatally stabbed his mother and wounded his brother. Family made repeated but unsuccessful efforts to get him help beforehand
13 recommendations Report PDF
East of England
Independent investigation: Samantha Ho, St Neots (2015)
Paranoid schizophrenic beheads wife and stabs family dog. Long MH history
7 recommendations Report PDF
Midlands
Independent investigation: Samuel Vernon, Nottingham (1993)
Paranoid schizophrenic fatally stabs man and attempts murder of another. Ind Inq 1993. Many previous admissions
-1 recommendations Report PDF
Midlands
Independent investigation: Sandra Bainbridge, Belper (2013)
Mentally ill woman breaks into house and kills pensioner. Long History of mental illness – recent contact
5 recommendations Report PDF
Wales
Independent investigation: Sandra Bowring (Vincent), Rhyl, Denbighshire (2006)
MH patient fatally stabs woman five times. Ind Inq 2008. Long MH history – failings – avoidable – High risk to others
13 recommendations Report PDF
North West
Independent investigation: Sandra Brotherton, Stockport (2014)
Paranoid schizophrenic repeatedly and fatally stabs mother. History of MH problems – Failed to take meds
22 recommendations Report PDF
East of England
Independent investigation: Sandra Crawford, St Albans (2010)
Psychotic man fatally and repeatedly stabs neighbour. Family took him to hospital day before but released.
18 recommendations Report PDF
North West
Independent investigation: Sandra Wilson, Newton le Willows (2006)
Mental Health Patient fatally strangles acquaintance. Prev history of depression & suicide attempts
-1 recommendations Report PDF
Midlands
Independent investigation: Sandy Hadfield, Lincoln (& Derby) (2002)
Sexual predator with long MH history kills teenager. SCR 2006. Long MH history – Previous violence
1 recommendation Report PDF
London
Independent investigation: Sanita Kaura, West London (1994)
Paranoid schizophrenic ran over and killed stranger. Ind Inq 1996
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: Sarah Jane Coghlan, Middlesbrough (2003)
MH patient fatally stabs woman with bayonet (6mnths after release for previous murder).. Ind Inq 2006
-1 recommendations Report PDF
South East
Independent investigation: Sarah Lawson, Worthing (2000)
Depressive strangled mentally ill daughter. Ind Inq 2004
26 recommendations Report PDF
South East
Independent investigation: Sarah Smart, Oxford (2005)
Depressive MH patient fatally stabs ex-wife. Ind Inq 2005 Recent contact w services
9 recommendations Report PDF