Investigations in the NHS

Mr A , who was a service-user under Avon and Wiltshire Mental Health Partnership NHS Foundation Trust

This review should be read in conjunction with the report below, ‘Multi-agency systems review to identify the learning following five homicides in Devon (2018-2019); with a focus on mental health care and management in custody’ NHS England has published a mental health homicide review into the care and treatment of Mr A , who was a service-user under Avon and Wiltshire Mental Health Partnership NHS Foundation Trust, Devon Partnership NHS Trust and Cygnet Health Care between June 2016 and Decembe

The investigation was prompted by an incident in Birmingham in 2020 that resulted in: 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:

NHS England commissioned a limited scope independent review into patient safety concerns and governance processes related to the North East Ambulance Service. Chaired by Dame Marianne Griffiths DBE, the review considered the facts surrounding a number of individual cases, reviewed the processes surrounding coronial investigations and reviewed the seven previous investigations and reviews undertaken by the ambulance service to determine if they were sufficient to fully understand and resolve issu

Greater Manchester Mental Health NHS FT

This is the full report of the independent investigation report into the care and treatment of service user Mr E. Following an incident in February 2020 Mr E pleaded guilty to manslaughter on the grounds of diminished responsibility and is now an inpatient at a high secure hospital. At the time of the incident, Mr E was under the care of Greater Manchester Mental Health NHS FT . These documents have also been published by:

University Hospitals of Morecambe Bay NHS Foundation Trust

These documents have also been published by: University Hospitals of Morecambe Bay NHS Foundation Trust NHS Lancashire and South Cumbria

Norfolk and Suffolk NHS Foundation Trust

This report was commissioned by the trust and made twelve recommendations to improve the care and treatment of service users, and three recommendations to improve practice following a serious incident. The investigation was prompted by the death of an 84-year-old gentleman who had been walking his dog in a remote wooded area in Norfolk by a 23-year old man. At the time of the homicide the young man was not under the care of mental health services, but he had had three previous episodes of care p

Somerset NHS Foundation Trust

NHS England has published an independent investigation report into the care and treatment of Mr D , a newly-referred patient of mental health services in Somerset, who killed his neighbour in 2020. An action plan in response to the report’s recommendations has been published by Somerset NHS Foundation Trust. NHS England has also published a shared learning bulletin to distil the findings and lessons from the main investigation report.

Mersey Care NHS Foundation Trust

These are the full report and lessons learned bulletin of the independent investigation report into the care and treatment of service user Mr E. Following an incident in January 2019, Mr E was convicted of murder. At the time of the incident, Mr E was under the care of Mersey Care NHS Foundation Trust. These documents have also been published by:

The investigation resulted from the death of a 59 year-old woman in 2018 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. The way that mental health services are delivered in Herefordshire has changed since the incident in 2018 (please see here for more details). That’s wh

CAMHS provision at West Lane Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust

This is a system-wide independent investigation into concerns and issues raised relating to the safety and quality of CAMHS provision at West Lane Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust. Tees, Esk and Wear Valleys NHS Foundation Trust has also published an assurance statement on their website here.

Mersey Care NHS Foundation Trust

These are the Executive Summary report and a Lessons Learnt bulletin of the independent investigation report into the care and treatment of service user Ben. Executive Summary report Lessons Learned bulletin Ben was convicted of manslaughter in January 2019. At the time of the homicide Ben was receiving care and treatment provided by Mersey Care NHS Foundation Trust. These documents have also been published by:

This is the independent investigation into the care and treatment of Ms F in Cumbria, Northumberland, Tyne and Wear Foundation Trust. Cumbria, Northumberland, Tyne and Wear Foundation Trust has also published an assurance statement into this case.

NHS England has published an independent investigation report into the treatment and care of ‘Mark’ , who killed his step-grandfather after moving from Nottinghamshire to Dorset in 2018. Action plans in response to the report’s recommendations have been published by:

An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust

This is the independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust. Tees, Esk and Wear Valleys NHS Foundation Trust has also published an assurance statement into this case .

An independent investigation into the care and treatment of Emily at Tees, Esk and Wear Valleys NHS Foundation Trust

This is the the independent investigation into the care and treatment of Emily at Tees, Esk and Wear Valleys NHS Foundation Trust and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust . Tees, Esk and Wear Valleys NHS Foundation Trust has also published an assurance statement into this case .

Devon Partnership NHS Trust

NHS England has published a summary mental health homicide review into the care and treatment of Mr S , who was a service-user under the care of Devon Partnership NHS Trust. Mr S fatally stabbed his father at his parents’ home in 2019. Devon Partnership NHS Trust and NHS Devon have both published a joint action plan on their websites, in response to the report’s recommendations. The action plans are available at:

Tees, Esk and Wear Valleys NHS Foundation Trust

This is independent investigation into the care and treatment of Nadia in West Lane Hospital by Tees, Esk and Wear Valleys NHS Foundation Trust . Tees, Esk and Wear Valleys NHS Foundation Trust has also published an assurance statement into this case .

This is the independent investigation report into the care and treatment of M published on 22nd November 2022.

This is the Joint Safeguarding Adult Review and Independent Mental Health Homicide Investigation, Ms G and Mr Q published on 10th November 2022.

East Kent Hospitals University NHS Foundation Trust · Dr Bill Kirkup CBE

Independent investigation into maternity and neonatal services at East Kent Hospitals University NHS Foundation Trust (QEQM Hospital, Margate and William Harvey Hospital, Ashford), covering care provided 2009–2020. Reviewed over 200 cases involving avoidable harm to mothers and babies. Found a culture of not listening to women, poor teamworking, and a trust focused on "looking good while doing badly". Published October 2022. Government accepted all recommendations July 2023.

Tees Esk and Wear Valley NHS Foundation Trust

This is the independent review of the investigation undertaken by Tees Esk and Wear Valley NHS Foundation Trust into the care and treatment of Mr H. Tees Esk and Wear Valley NHS Foundation Trust has also published an associated action plan which can be found here.

This is the independent investigation report into the care and treatment of Mr Y published on 5th October 2022. Mr Y was in receipt of services in South London.