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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: Stuart Hopkin, Shepton Mallet (2020)
Delusional mentally ill pensioner repeatedly and fatally stabs his neighbour. Seen by MH staff previous day but not admitted due to lack of beds
6 recommendations Report PDF
Scotland
Independent investigation: Stuart Robertson, Glasgow (2004)
MH patient killed victim with hammer. Prev discharged from psych hospital. History of serious violence
-1 recommendations Report PDF
South East
Independent investigation: Sue Goswell, West Chiltington, Sussex (2007)
Mentally ill man fatally stabbed wife then kills himself, a week after leaving psychiatric hospital. Many previous warnings. MH history – released from Psych hospital despite warnings from daughter
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: Suryakant Patel, Harlington, London (2006)
Psychotic schizophrenic battered stranger to death, soon after release from Halifax psych hospital.. Ind Inq (2006/8119) 2009
4 recommendations Report PDF
North East and Yorkshire
Independent investigation: Susan Atkinson, Hull (2018)
Mentally ill woman with history of serious violence fatally batters neighbour. 12 prev Psych inpatient admissions, off meds
6 recommendations Report PDF
London
Independent investigation: Susan Barry, Manchester (1996)
MH patient kills estranged wife. South London patient – Ind Inq 1997
-1 recommendations Report PDF
London
Independent investigation: Susan Crawford, Herne Hill (1994)
MH patient fatally stabs victim. Ind Inq 1998
-1 recommendations Report PDF
East of England
Independent investigation: Suzanne Brown, Braintree (2017)
Paranoid schizophrenic repeatedly and fatally stabbed partner after meds stopped. Family warned repeatedly about deterioration
7 recommendations Report PDF
London
Independent investigation: Suzanne Kopernik Stekel, South Norwood (1996)
MH patient stabs mother then cuts own throat. Ind Inq 1997
-1 recommendations Report PDF
London
Independent investigation: Tamara Holboll, Kentish Town (2014)
Paranoid schizophrenic fatally stabs mother and sets flat alight. Tried to access care days before but no beds
12 recommendations Report PDF
South West
Independent investigation: Tammy Little, Hayle Toans, Cornwall (2000)
Paranoid schizophrenic strangles partner. Ind Inq 2003 found serious failings
2 recommendations Report PDF
Midlands
Independent investigation: Terence Hooper, Kettering (2008)
Ex High Secure Mental Health Patient fatally punches man. Inq found he had been released too early from Rampton
11 recommendations Report PDF
South West
Independent investigation: Terrance Hall, Weston Super Mare (2008)
Mental health patient beats neighbour to death in row over washing machine. MH history.Ind inq. 2013 HASCAS
-1 recommendations Report PDF
London
Independent investigation: Terrence Anthony Boyn(e)s, Bexley (2004)
Homicide by mentally ill. Ind Inq. 2010
2 recommendations Report PDF
East of England
Independent investigation: Terry Ojuederie, Peterborough (2015)
Psychotic man beats cell mate to death. Substance abuse history
11 recommendations Report PDF
Midlands
Independent investigation: Terry Radford, Mansfield Woodhouse (2019)
Mentally ill man in stolen car fatally reverses over stranger, after assaulting a family claiming he was Jesus. Convicted Manslaughter by diminished responsibility
5 recommendations Report PDF
London
Independent investigation: Terry Wilson, Wewlyn Garden City (2006)
Paranoid Schizophrenic fatally and repeatedly stabbed father. Previous inpatient – discharged month before incident. Failed to take meds. Ind Inq.
8 recommendations Report PDF
South East
Independent investigation: Thelma Allum, Maidenhead, Berks (1997)
MH homicide of wife, after attacking mother days earlier. Ind Inq 2000
7 recommendations Report PDF
South West
Independent investigation: Thomas Abraham, Gloucester (2019)
Paranoid schizophrenic fatally stabs mentally ill man whilst suffering relapse. Indefinite hospital order with restrictions
5 recommendations Report PDF
East of England
Independent investigation: Thomas Baird, Hemel Hempstead (2013)
Recent MH patient batters and stabs ex-girlfiend’s father. Previous history of violent assaults
-1 recommendations Report PDF
North West
Independent investigation: Thomas Jones, Manchester (2017)
Mentally disordered man fatally stabs vulnerable man and sets his body alight. Convicted of murder – had killed before but had been released
-1 recommendations Report PDF
North West
Independent investigation: Thomas Thompson, Liverpool (2011)
Mental Health patient fatally batters man with variety of implements. History of violence. Previous inpatient month before incident
10 recommendations Report PDF
South East
Independent investigation: Timothy Hutcheon, Chatham (2009)
MH patient repeatedly and fatally stabs acquaintance. Long MH history
8 recommendations Report PDF
North East and Yorkshire
Independent investigation: Tina Stevenson&2 babies, Hull (2005)
Paranoid Schizophrenic kills heavily pregnant stranger (twins) after rowing with mother.. Ind Inq (2005/95) 2009. Recently released from Psych unit, missed meds. Previous threats to kill.
9 recommendations Report PDF
London
Independent investigation: Tom Easton, Old St, London (2006)
Paranoid Schizophrenic stabbed youth worker whilst on day release. Earlier stabbed solicitor in eye. Ind Inq due
9 recommendations Report PDF