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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: Sean Hand, Basildon (2003)
MH Homicide by stabbing. Ind Inq 2008. Released despite homicidal thoughts, poor records
7 recommendations Report PDF
London
Independent investigation: Senait Mezgebe, Wandsworth (1998)
Paranoid schizophrenic fatally stabs his sister, his carer. Ind Inq 2003
-1 recommendations Report PDF
South West
Independent investigation: Sergio Marquez, Bournemouth (2012)
Paranoid schizophrenic repeatedly and fatally stabs flatmate and mutilates body. London patient, had absconded from Huntley MH unit months before
4 recommendations Report PDF
Midlands
Independent investigation: Shamim Akhtar, Birmingham (2000)
Paranoid schizophrenic fatally stabbed wife in front of children whilst on unsuper-vised release from MH unit. Critical Ind Inq 2004
60 recommendations Report PDF
Northern Ireland
Independent investigation: Sharon Moore, Lisburn (2003)
Paranoid Schizophrenic fatally stabbed and mutilated woman, a month after release from Psych hospital. Ind Inq 2006. Known risk of violence to others, just released from Psych hospital
48 recommendations Report PDF
South West
Independent investigation: Sharon Stokes, Exmouth (2007)
MH patient kills woman with brick. Family had tried to get him sectioned beforehand
14 recommendations Report PDF
South West
Independent investigation: Sharon Wall, Gloucester
Psychiatric patient fatally stabbed care assistant in hospital. Had previously killed twice before – wanted to avoid move to MH unit which was non-smoking with no wi-fi.
3 recommendations Report PDF
South West
Independent investigation: Shaun O’Neill, Modbury (2013)
Paranoid schizophrenic fatally strangles then stabs young son. Long MH history, prev. inpatient
7 recommendations Report PDF
London
Independent investigation: Shivani Taneja Kapoor, Northwood (2013)
Depressed and mentally disordered man fatally strangles his wife. Convicted of murder – life with a minimum of 16 years
9 recommendations Report PDF
North West
Independent investigation: Sidney Waller, Manchester (2008)
Paranoid schizophrenic fatally stabs stranger. internal inquiry found many failings
-1 recommendations Report PDF
South East
Independent investigation: Simeon Claxton, Petersfield, Hampshire (2004)
Mentally ill man fatally stabs friend then commits suicide (victim was also mentally ill). Ind Inq 2007- previous inpatient
7 recommendations Report PDF
London
Independent investigation: Simon Breed, Wood Green (2004)
Mentally ill man repeatedly and fatally stabbed neighbour. Ind Inq 2010
-1 recommendations Report PDF
North West
Independent investigation: Simon Sutton, Birkenhead (2007)
MH patient fatally batters sister’s boyfriend with pool cue and kidnaps acquaintances. Critical Inquiry – D&A2012-Verita
11 recommendations Report PDF
South East
Independent investigation: Simon Widger, Eastbourne, Sussex (2000)
Psychotic glued partners eyes, ears and lips and fatally and repeatedly stabbed him. Ind Inq, 2003
9 recommendations Report PDF
London
Independent investigation: Simran Sidhu (5)Aman Raj (23 mths), Southall Station (2005)
Mentally ill woman jumps in front speeding train with her children. Long history of depression. Had sought treatment, no team work
18 recommendations Report PDF
London
Independent investigation: Sindi Smith (SS), Stratford. London
MH patient fatally stabbed girlfriend 22 times with a samurai sword, nine days after she gave birth. Ind Inq 2006. Long MH history, previous violence
17 recommendations Report PDF
Midlands
Independent investigation: Sohbia Khan, Derby (2017)
Paranoid schizophrenic kills wife in ‘savage’ attack. Had previously served hospital order for seriously assaulting another partner
11 recommendations Report PDF
London
Independent investigation: Stefan Melnyk, Acton (2020)
Paranoid schizophrenic fatally runs a man over and seriously wounds another with a knife. Long history of mental illness
3 recommendations Report PDF
South East
Independent investigation: Stefan Welch, Brighton (2010)
Mentally ill man kills acquaintance and sets body alight
-1 recommendations Report PDF
London
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999)
Schizophrenic fatally pushed stranger in front of train. Ind Inq 2003. Long MH history.
-1 recommendations Report PDF
Midlands
Independent investigation: Stephanie Barton, Boston (2007)
Psychotic man fatally and repeatedly stabs girlfriend. Heavy cannabis user. Tried to access help without success
4 recommendations Report PDF
North West
Independent investigation: Stephen O’Brien, Crewe (2016)
Mentally disordered man convicted of fatally stabbing man
9 recommendations Report PDF
Wales
Independent investigation: Stephen Rees, Cardiff (2011)
Paranoid schizophrenic fatally slashes hostel resident’s throat. Victim was also mentally ill
6 recommendations Report PDF
South West
Independent investigation: Steven Hoskin, St. Austell (2006)
MH patient tortures and murders learning disabled man. Drug history – known MH patient
15 recommendations Report PDF
East of England
Independent investigation: Steven Janczuk, Arlesey, Beds (2006)
Mentally ill woman fatally stabs husband. MH History
9 recommendations Report PDF