Investigations in the NHS

This is an independent review of the care and treatment received by George and Charles prior to an incident of homicide.

This is the summary report of an assessment of a mental health trust’s internal investigation of the care and treatment of MB.

Hampshire and Isle of Wight Healthcare NHS FT

This is the report of the care and treatment of Mr Christopher Stone-Houghton APRIL 2025

This independent review commissioned by NHS England looks at the care and treatment that Colin received between January 2021 and his subsequent death in September 2021. The review included the nature and extent of involvement of all agencies, private and NHS, that Colin had contact with, dating back to his first contact with services in relation to his symptoms of confusion. Documents

This is the shared learning bulletin from an independent review into the care and treatment given George .

Hampshire and Isle of Wight Healthcare NHS FT

This is the report of the care and treatment of Mr Christopher Stone-Houghton APRIL 2025

This is the summary report of an assessment of a mental health trust’s internal investigation of the care and treatment of JP.

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

This is the executive summary of the independent investigation into the care and treatment of patient D.

The investigation was commissioned by NHS England following the fatal stabbings of three people in Nottingham in June 2023. Three others sustained serious injuries. The purpose of the investigation is to help the NHS and partners understand if there are lessons that could be learned that could prevent something similar happening in the future. The report published shares all the findings and recommendations for that purpose. NHS Nottingham and Nottinghamshire Integrated Care Board and Nottingham

This is the executive summary of the independent investigation into the care and treatment of patient E.

This is the shared learning bulletin from an independent review into the care and treatment given to Mr G.

Tees, Esk and Wear Valleys NHS Foundation Trust

This is a Quality Assurance Review of practice and governance at Tees, Esk and Wear Valleys NHS Foundation Trust. Shared learning from the review has also been published and is available to download here.

Central and North-West London NHS Foundation Trust

A pathway review was commissioned by NHS England to understand the service changes made after a serious incident involving a death several years ago. The perpetrator was a young man who had been admitted informally via Street Triage with psychotic symptoms, but he left the ward without permission and police subsequently established that a young woman had been killed. Central and North-West London NHS Foundation Trust is responsible for a number of actions identified within the teview and hold a

Norfolk and Suffolk Mental Health NHS Foundation Trust

This independent review report has been commissioned by NHS England relating to the care provided by Norfolk and Suffolk Mental Health NHS Foundation Trust for an individual who was responsible for the death of their grandmother. This report aims to strengthen local services in the context of the evidence and relevant information about the incident. The report supports learning and informs the NHS and the public on future service provision.

· Dr Hilary Cass

Independent review commissioned by NHS England and NHS Improvement in 2020, led by Dr Hilary Cass (retired consultant paediatrician, former President of the RCPCH). Published April 2024. Examined gender identity services for children and young people provided by GIDS at the Tavistock and Portman NHS Foundation Trust. Found services had expanded rapidly without an evidence base; poor clinical governance; inadequate follow-up of patients; and an unclear rationale for puberty blocker prescribing. Made 32 recommendations. NHS England accepted all 32. GIDS closed March 2024 and was replaced by two new regional services.

The investigation resulted from the death of a woman and her male child in 2021 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the investigation was to help the NHS and partners understand if there are lessons that could be learned that could prevent something similar happening in the future.

This document has also been published by:

Greater Manchester Mental Health NHS Foundation Trust

Final report This is the final report 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 report was commissioned by NHS England following concerns raised by patients, their families, and staff, some of which were presented through the media. This

This is the independent investigation report into the care and treatment of Mr D published on 2 November 2023.

This is the independent investigation report into the care and treatment of AB published on 18th October 2023.

The investigation resulted from the death of a 87 year-old man in 2019 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the investigation was to help the NHS and partners understand if there are lessons that could be learned that could prevent something similar happening in the future.

York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust

NHS South Yorkshire commissioned an independent investigation into the death of Yusuf and the care and treatment he received from his first contact with health services on 15 November 2022 . The report makes a number of recommendations for organisations involved in his care and treatment which, while they would not have changed the course of events for Yusuf, should be implemented to ensure there is learning from this case. The independent report can be viewed here. The Rotherham NHS Foundation

Lancashire and South Cumbria NHS FT

These documents represent Part A and Part B of the full report for the independent investigation of the care and treatment of Mr X and the Lancashire Pathway Review. Following an incident in 2019, Mr X was charged with murder. Consequently, he was convicted of manslaughter and given a life sentence. He is currently detained in a high secure mental health hospital. At the time of the incident, Mr X was under the care of Lancashire and South Cumbria NHS FT. In November 2020, NHS England commission