Investigations in the NHS

Schizophrenic repeatedly and fatally stabbed friend. Many failings – serious incident was ‘foreseeable’

Psychotic MH patient fatally stabs father.. Ind Inq 1996

Paranoid schizophrenic fatally stabs WPC. Ind Inq 1999

Detained paranoid schizophrenic leaves hospital without permission and kills brother in law. Ind Inq 2005

Severely depressed mother kills herself and young son at railway station

Greater Manchester Mental Health NHS Foundation Trust

Final report This is the Assurance Review of the Independent Review into the care and treatment provided by Greater Manchester Mental Health NHS Foundation Trust, following failings within the trust’s services, reported at the Edenfield Centre, and the failure within the organisation to escalate concerns and mitigate against patient harm. This review was commissioned by NHS England and is focussed on the actions that have been progressed and implemented in response to the recommendations made in

Final report This is the final report of the Independent Investigation into the adequacy of previous hospital-level investigations into the clinical practice and leadership of Consultant Surgeon A, to determine whether further action is required. This report, independently chaired by Dr Yvette Oade, was commissioned by NHS England following ongoing concerns from patients, families, MPs and ministers. This review is also published by:

· Niche

NHS England East of England Region and Midlands Region, commissioned Niche Health and Social Care Consulting Ltd (Niche) to carry out an independent investigation into the care and treatment of mental health service user, Sam. Documents:

Review for the recommendations resulting from several serious incident investigation and governance reports involving Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

This is a Quality Assurance Review for the recommendations resulting from several serious incident investigation and governance reports involving Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and other local stakeholders.

12 NHS trusts across England · National Maternity and Neonatal Investigation

Independent investigation into maternity and neonatal services across 12 NHS trusts in England, chaired by Baroness Valerie Amos. Interim report published 26 February 2026 examining capacity pressures, culture and leadership, racism and discrimination, poor accountability, estate quality, and workforce challenges. No recommendations made in this interim report; evidence gathering ongoing. The investigation engaged over 400 family members and received 8,000+ public submissions.

· NHS Performance and Improvement

National assurance assessment of maternity and neonatal services across Wales, commissioned by the Cabinet Secretary for Health and Social Care in May 2025. Chaired by Professor Sally Holland (former Children's Commissioner for Wales). The panel visited maternity units throughout Wales and consulted hundreds of women, families and staff. Identifies strengths and vulnerabilities across capacity, culture, racism and discrimination, accountability, estates and workforce. All recommendations accepted by Welsh Government with three-year phased delivery programme.

This document provides an overview of key findings from an independent investigation into the NHS care of a young man (Mr N) who killed a close relative. The subsequent investigation, carried out by Psychological Approaches, identified six recommendations, which are set out in the published learning summary . Key findings of the review relate to information sharing and joint working; risk assessment; and care planning. Agencies and teams who might benefit from this bulletin

Published January 2026 The executive summary of an independent investigation into the care and treatment given to Adult 1, a mental health service user, who fatally attacked a family member, Adult 2, in 2021. This accompanies the learning bulletin above. Click here for the executive summary.

This is the executive summary of the independent investigation into the care and treatment of Mr P.

· Niche

This investigation relates to the care and treatment of an adult female (referred to as Ms P in the document) who was known to local mental health services prior to her conviction for homicide in 2023. The subsequent investigation, carried out by Niche consulting, identified four recommendations, which are set out as Critical Learning Points in the shared learning bulletin . These recommendations relate to Individual practice; Governance focussed learning; Board assurance; and System learning po

This summary reviews the findings of an independent assurance review conducted to evaluate the care and treatment provided to PS by mental health services. The review was initiated after a tragic incident involving PS, which highlighted significant failures in care coordination, clinical management, and service pathways. Documents

This Mental Health Homicide Review (MHHR) has been commissioned by NHS England regarding person ‘X’ who had been in contact with mental health services. X died from a fall from a height. X’s wife, Y, was subsequently found to have died due to strangulation. The Major Crime Team concluded that the deaths were due to murder and suicide. Documents Independent Assurance Review – Assurance of the investigation report and action plan relating to the care and treatment received by PS prior to homicide

The aim of this report is to help improve the delivery of care for people who are at risk of self-harm. Mr B was a 50-year-old man who had been living with secondary progressive multiple sclerosis (MS) for over 20 years and was living in a care home. On 27 May 2023, Mr B left the assessment unit of Brook Meadows House (BMH) where he had been living since 10 June 2022, and travelled to Kent, where he ended his life. Documents

This is a learning bulletin from an independent review of Mr M’s care and treatment published on 15 October 2025.

This investigation relates to the care and treatment of Mr B during the period between October 2020 and 11 July 2023 when a homicide took place. At the time of the incident the service user was receiving care from a Community Mental Health Team. In October 2023, the NHSE Independent Investigation Review Group commissioned an investigation. The following document represents a learning summary of this independent review, carried out by Psychological Approaches CIC, and the Trust has provided NHS E

· Niche

NHS England Midlands Region, commissioned Niche Health and Social Care Consulting Ltd to carry out an independent investigation into the care and treatment of mental health service user SV following a domestic homicide in 2017. The main purpose of an independent investigation is to ensure that mental health care-related homicides are investigated in such a way that lessons can be learned effectively to prevent recurrence. The investigation process may also identify areas where improvements to se

This is the executive summary of the independent investigation into the care and treatment of Mr L.

Black Country Healthcare NHS Foundation Trust

A Pathway Review of care for people with severe mental ill health who present a level of risk to others in Black Country Healthcare NHS Foundation was designed to support learning and development following an incident that occurred in 2016. The work was commissioned by NHS England and led by our independent clinical team. The main report contains information about the methodology, the background, findings and agreed recommendations.

This is the shared learning bulletin from an independent review of a young person’s care pathway.

Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud Nazir Appendices The report has also been published on the following websites: