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Investigations in the NHS

896 investigations 6864 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 6,864 recommendations. 76% of investigations have extracted recommendations. 680 investigations have recommendations tracked.

Investigations

Click an entry for full report & recommendations
South East
Independent investigation: Anita Bawtree, Southampton (2011)
Psychotic man fatally and repeatedly stabbed partner. Extensive Drug history. Recently released from MHA
28 recommendations Report PDF
Scotland
Independent investigation: Anne Morris, Troon (2012)
Mentally ill man kills mother and attacks father who survives. Patient of Sussex Partnership Trust in England
5 recommendations Report PDF
South East
Independent investigation: Annette Sturt, Dover (2012)
Paranoid schizophrenic fatally batters and strangles his mother. Heavy drug abuse
3 recommendations Report PDF
North East and Yorkshire
Independent investigation: Annie Garbutt, Mirfield (2007)
Mentally ill woman batters grandmother to death with garden spade. Ind inq. Verita, 2012
8 recommendations Report PDF
South East
Independent investigation: Anthony Harrison, Andover (1998)
Detained MH patient leaves hospital and fatally stabs man. Ind Inq 2001. Later hanged himself at Broadmoor
16 recommendations Report PDF
London
Independent investigation: Anthony Kellman, Brixton (1994)
Psychotic fatally shot one stranger and knifed another after mistakenly released from hospital. Ind Inq 2001 (!) – catalogue of errors – no risk ass, previous firearms use, Comm failures
9 recommendations Report PDF
Wales
Independent investigation: Anthony Kitely, Cardiff (2009)
Schizophrenic man attempted to kill his mother then fatally and repeatedly stabbed his friend. Long MH history, recently released by MHRT against advice
15 recommendations Report PDF
South West
Independent investigation: Anthony Payne (80)Dick Carter (84)Roger Carter, Exeter (2019)
Paranoid schizophrenic fatally batters elderly strangers with a hammer and spade. Previous inpatient, released twice by police, Dr said not detainable despite violence and talking of unicorns
12 recommendations Report PDF
South East
Independent investigation: Anthony Radford, Pewley Down, Guildford (2005)
Paranoid schizophrenic fatally and repaetedly batters man with log. MH History. (Ind Inq 2013, Verita)
-1 recommendations Report PDF
North West
Independent investigation: Anthony Rigby, Blackburn (2002)
Schizophrenic with history of violence fatally shot friend in the back of the head, three months after release from hosptal. Critical Ind Inq 2003
-1 recommendations Report PDF
South East
Independent investigation: Anthony Wakeford, Effingham (2010)
Mentally ill woman fatally stabs husband. Released at trial
8 recommendations Report PDF
Midlands
Independent investigation: Anthony Winship, Notts (1996)
MH Patient kills father after stabbing and repeatedly hitting him with hammer.. Ind Inq 1997
-1 recommendations Report PDF
London
Independent investigation: Antonio Tommaso, New Barnet (2014)
Paranoid schizophrenic repeatedly and fatally stabs friend & sets flat alight. Not taking Meds – Long MH history
9 recommendations Report PDF
North East and Yorkshire
Independent investigation: Arthur Lingard, Grimsby (2004)
Paranoid schizophrenic fatally batters stepfather. Critical Ind Inq (2004/487) 2008 -Few notes, inexperienced staff, warnings by family
3 recommendations Report PDF
North East and Yorkshire
Independent investigation: Ashleigh Ewing, Heaton, Newcastle (2006)
Paranoid schizophrenic fatally stabbed mental health worker 39 times with four knives.. Prev. attacked parents with hammer (GBH). Prev. arrested at Buck Pal threatening Queen. Refused medication, realised was danger to others.
-1 recommendations Report PDF
London
Independent investigation: Asiya Khatun, Newham (2000)
Mentally ill man fatally strangles his wife. Ind Inq 2002
-1 recommendations Report PDF
South East
Independent investigation: Avril Hollens, Tonbridge, Kent (1999)
MH patient fatally stabs girlfriend. Ind Inq 2003
-1 recommendations Report PDF
London
Independent investigation: Aysel Djevdet, Palmers Green (2009)
Psychotic depressive man fatally strangles wife
12 recommendations Report PDF
London
Independent investigation: Badi Saleem, Kings Cross (2011)
Paranoid schizophrenic fatally stabs man
10 recommendations Report PDF
East of England
Independent investigation: Barbara Coleman, Beds (1997)
Man with schizophrenia fatally stabbed a fellow patient. Ind Inq 1998
-1 recommendations Report PDF
London
Independent investigation: Beata Slomiana, Finchley (2010)
Paranoid schizophrenic kills girlfriend by putting plastic bag over her head. MH history – not taking meds
4 recommendations Report PDF
London
Independent investigation: Beatrice Hughes, Harrow (1997)
MH patient fatally punched kicked & stamped on pensioner during burglary. Ind Inq 2000
26 recommendations Report PDF
South East
Independent investigation: Ben Cargill (Mr D), Chesham, Bucks (2004)
Mentally ill man repeatedly and fatally stabbed former flatmate. Ind Inq 2006
14 recommendations Report PDF
London
Independent investigation: Benjamin Durao, Brixton (2004)
Mentally ill teenager fatally stabs man. MH history.(Ind Inq. 2010 NHS)
4 recommendations Report PDF
North West
Independent investigation: Bernadette FoxSarah Fox, Bootle (2015)
Paranoid Schizophrenic strangles mother and fatally stabs sister. Off meds and abusing substances
13 recommendations Report PDF