Investigations in the NHS

Devon Partnership NHS Trust

NHS England has published a mental health homicide review into the care and treatment of Patient A , who was a service-user under the care of Devon Partnership NHS Trust. Patient A fatally stabbed a stranger outside a shopping centre in 2018. 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:

An independent investigation into the dissolution of the independent midwifery provider One to One Midwives. One to One Final Report Appendices – August 2022 post One to One Midwives was an independent sector provider established in 2010 to provide maternity services to NHS-funded clients through a midwifery-led, community-based, ‘case loading’ model. One to One Midwives was one of a small number of similar businesses over the last ten years which aimed to bridge the gap between greater choice a

Leicestershire Partnership NHS Trust

The investigation was prompted by the death of a 92 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. An Independent Investigation into the care and treatment of Tom Action Plan – Leicestershire Partnership NHS Trust

Published August 2022 This is the independent quality assurance review of the care and management of Mr F . South West Yorkshire Partnership NHS Foundation Trust

This is the independent quality assurance review of the care and management of Mr F . South West Yorkshire Partnership NHS Foundation Trust has also published an assurance statement into this case .

Norfolk and Suffolk NHS Foundation Trust

The independent assurance review provides an assessment of the implementation of the actions developed in response to recommendations from the independent investigation into the care and treatment of Mr K in Suffolk.

This is the report of the independent investigation into the care and treatment of a mental health service user Mr J in Kent. At the time of the homicide (2018), Mr J was under the care of the Early Intervention in Psychosis team at Kent and Medway NHS and Social Care Partnership Trust.

This is the independent investigation report into the care and treatment of Mr X published on 13th June 2022. Mr X was in receipt of services in South West London.

Greater Manchester Mental Health NHS Foundation Trust

An independent investigation into the care and treatment of Ms A This is the Executive Summary of the independent investigation report into the care and treatment of Ms A. Ms A was convicted of manslaughter in December 2020. At the time of the homicide Ms A was receiving care and treatment provided by Greater Manchester Mental Health NHS Foundation Trust. The Executive Summary has been published by: This is the Assurance Review for the actions taken by Greater Manchester Mental Health NHS Founda

Published May 2022 This is the extended executive summary of the independent investigation into the care and treatment of Mr G. South West Yorkshire Partnership NHS Foundation Trust

This is the extended executive summary of the independent investigation into the care and treatment of Mr G. South West Yorkshire Partnership NHS Foundation Trust has also published an assurance statement into this case.

NHS England has published a Root Cause Analysis Investigation Report into the Death of Dr Julien Warshafsky . The focus of this case review is to explore opportunities for collective learning and identify actions that could be either considered or taken to minimise the risk of recurrence.

This is the independent assurance review for Mr X published on 4th April 2022. Mr X was in receipt of services in South West London.

Published 30 March 2022 This is the extended executive summary of the independent investigation into the care and treatment of Mr G. Bradford District Care NHS Foundation Trust

This is the extended executive summary of the independent investigation into the care and treatment of Mr G. Bradford District Care NHS Foundation Trust has also published an assurance statement into this case.

The Shrewsbury and Telford Hospital NHS Trust · Donna Ockenden

Independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, commissioned by the Secretary of State for Health and Social Care in 2017. Led by Donna Ockenden (senior midwife). Final report published 30 March 2022. Reviewed 1,486 families over 20 years (2000–2019), finding repeated failures in care involving three maternal deaths and multiple baby deaths and brain injuries. Identified a culture of not listening to women, poor teamworking, and failure to learn from adverse events. Made 15 Immediate and Essential Actions (IEAs) applicable to all NHS trusts, and 64 Local Actions for Learning specific to the trust. Government accepted all national recommendations on publication and committed £127m to maternity services improvement.

NHS England has published an independent investigation report into the care and treatment of Mr K , a patient of mental health services in Somerset, who killed another man in Honiton in June 2017. An action plan in response to the report’s recommendations has been published by Somerset Clinical Commissioning Group. NHS England subsequently published a quality assurance review to assess progress on the recommendations.

Published February 2022 This is the executive summary of the independent investigation into the care and treatment of Mr A. South West Yorkshire Partnership NHS Foundation Trust

This is the executive summary of the independent investigation into the care and treatment of Mr A. South West Yorkshire Partnership NHS Foundation Trust has also published an assurance statement into this case.

The investigation was prompted by the death of a 34 year-old man in 2017 and was commissioned by NHS England once all related criminal proceedings had been concluded. 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.

This is the independent investigation report into the care and treatment of Mr N published on the 10 th February 2022. Mr N was in receipt of services in West London.

This is the independent investigation report into the care and treatment of Mr N and Mr G published on 21st February 2022. Mr N and Mr G were in receipt of services in North London.

Cornwall Partnership NHS Foundation Trust

NHS England and NHS Improvement has published a mental health homicide review into the care and treatment of Mr T , who was a service-user under the care of Cornwall Partnership NHS Foundation Trust. Mr T took his own life in 2016 after being arrested on suspicion of murdering his baby son, who was subsequently found to have been unlawfully killed. Cornwall Partnership NHS Foundation Trust has published an action plan on its website, in response to the report’s recommendations. Kernow Clinical C

Mr A and Mr B on the 31st January 2022. Mr A and B were in receipt of services from South West London and St George’s Mental Health NHS Trust

This is the independent investigation report into the care and treatment of Mr A and Mr B on the 31st January 2022. Mr A and B were in receipt of services from South West London and St George’s Mental Health NHS Trust.

Cambridgeshire and Peterborough NHS Foundation Trust

The findings of an independent investigation into the circumstances surrounding the care and treatment of Mr D are published on this webpage. Mr D had a diagnosis of paranoid schizophrenia and recurrent depressive disorder. He was a recipient of mental health services provided by Cambridgeshire and Peterborough NHS Foundation Trust. On 27 November 2019 Mr D attacked Miss Y, another resident, in the common room of their supported accommodation. Miss Y sadly died later the same day. Mr D was found

This is the independent investigation report into the care and treatment of Mr X published on the 26 th January 2022. Mr X was in receipt of services from East London Foundation Trust.

This is the learning lessons bulletin into the care and treatment of Mr J .