Investigations in the NHS

NHS England and NHS Improvement has published a mental health homicide review into the care and treatment of Mr P, who was a service-user under the care of Livewell Southwest. He was jailed in 2017 for the manslaughter of his friend, Mr M, whose body had been found at Mr P’s address in December 2016. Livewell Southwest has published an action plan on its website , in response to the report’s recommendations. Following the report on Mr P, an independent quality-assurance review on implementation

This is the report of an assurance review of an independent investigation which considered the care and treatment of mental health service user Mr M in Greater Manchester An independent external assurance review report have been published by

Mr G published on the 16 th November 2021. Mr G was in receipt of services from Barnet, Enfield and Haringey Mental Health NHS Trust

This is the independent investigation report into the care and treatment of Mr G published on the 16 th November 2021. Mr G was in receipt of services from Barnet, Enfield and Haringey Mental Health NHS Trust.

Christie NHS Foundation Trust

The rapid review was commissioned by NHS England and NHS Improvement, following concerns raised by staff at The Christie Hospital, in relation to the Research & Innovation department. The review makes a number of recommendations and the Trust will be developing and action plan to address these. The Christie NHS FT Rapid Review

Tees, Esk and Wear Valleys NHS Foundation Trust

This is the report of the independent investigation into the care and treatment of Mr D. The associated action plan has been published by Tees, Esk and Wear Valleys NHS Foundation Trust .

This is the report of an assurance review of an independent investigation which considered the care and treatment of mental health service user Mr A in Greater Manchester This is the report of an independent assurance review of an independent investigation which considered the care and treatment of mental health service user Mr A in Greater Manchester, published 2020. An independent external assurance review report and associated assurance statement have been published by:

Mr H. At the time of the incident Mr H was receiving care from Lancashire and South Cumbria NHS Foundation Trust

An independent investigation into the care and treatment of Mr H This is the executive summary of the independent investigation report into the care and treatment of Mr H. At the time of the incident Mr H was receiving care from Lancashire and South Cumbria NHS Foundation Trust. The Executive Summary has been published by: This is the assurance review of the actions taken by Lancashire and South Cumbria NHS Foundation Trust and Lancashire and South Cumbria ICB following the publication of the in

User A, published on 8th September 2021. User A was in receipt of services from North East London NHS Foundation Trust

This is the independent investigation report into the care and treatment of User A, published on 8th September 2021. User A was in receipt of services from North East London NHS Foundation Trust and North East London CCG.

Stage 2 Independent Investigation into Southern Health NHS Foundation Trust

A recommendation of the Stage 1 Independent Report into Southern Health NHS Foundation Trust in February 2020 was a limited public investigation into a small number of specific policies and processes to determine the extent of progress and to make further recommendations for the Trust. These issues were: Here is the stage 2 report from the Independent Investigation Panel, Chaired by Mr Pascoe QC. Here are extracts of the stage 2 report featuring the Executive Summary, Recommendations and Conclus

David at North West Boroughs Healthcare NHS Foundation Trust

An independent assurance review of the independent investigation into the care and treatment of mental health service user David This is the report of an independent assurance review of an independent investigation which considered the care and treatment of mental health service user David at North West Boroughs Healthcare NHS Foundation Trust, published in June 2020. The independent external assurance review report and associated assurance statement have been published by:

This investigation was commissioned by NHS England and was conducted in partnership with the Domestic Homicide Review which was commissioned by Southend, Essex and Thurrock Domestic Abuse Board. The investigation was prompted by the death of a woman in Essex in 2020. 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.

Mr X, published on 25th August 2021. Mr X was in receipt of services from South London and Maudsley NHS Foundation Trust

This is the independent investigation report into the care and treatment of Mr X, published on 25th August 2021. Mr X was in receipt of services from South London and Maudsley NHS Foundation Trust.

The investigation was prompted by the death of a 37 year-old woman in 2017 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the investigation has been to help the NHS and partners understand if lessons can be learned that could prevent something similar happening in the future.

An independent investigation into the care and treatment of a mental health service user Ms C in Humber Teaching NHS Foundation Trust

This is the report of the independent investigation into the care and treatment of Ms C . An independent quality assurance review of the implementation of recommendations resulting from this independent investigation was published in August 2022 and is available here.

The findings of an independent investigation into the circumstances surrounding the care and treatment of Mr Z are published on this webpage: Essex Partnership University Trust and NHS Thurrock ICS, which are cited in the report’s recommendations, have also published an action plan an action plan in response to the findings.

Avon and Wiltshire Mental Health Partnership NHS Trust

NHS England has published an independent investigation report into the care and treatment of ‘Ian’ , a patient of Avon and Wiltshire Mental Health Partnership NHS Trust and of Cygnet Health Care, who killed another man in Bristol in July 2016 Action plans in response to the report’s recommendations have been published by: Avon and Wiltshire Mental Health Partnership NHS Trust Cygnet Health Care (for more information please contact communications@cygnethealth.co.uk ) Bristol Safeguarding Adult Bo

A in Northumberland, Tyne and Wear NHS Foundation Trust

This is the independent external quality assurance review following an internal investigation into the care and treatment of A. A post-publication assurance review in relation to the implementation of recommendations resulting from the investigation into the homicide committed by a mental health service user, A, can be viewed here .

An independent assurance review report into the care and treatment of mental health service user A This is the report of an independent assurance review of North West Boroughs’ internal investigation which considered the care and treatment of mental health service user A Mental health service user A was found guilty of manslaughter in May 2018. He was ordered by the court to be detained under Section 37/41 of the Mental Health Act (1983) to remain in the medium secure hospital. At the time of th

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

The findings of an independent investigation into the circumstances surrounding the care and treatment of Mother in Essex are published on this webpage. Mother had been under the care of secondary mental health services since March 2017. Following the homicide of Child R by his Mother in July 2018, NHS England commissioned an independent investigation into the care and treatment of mental health service user, Mother. An independent investigation into Mother and a related serious case review into

Mr S, published on 16th December 2020. Mr S was in receipt of services from Central North West London NHS Trust

This is the independent investigation report into the care and treatment of Mr S, published on 16th December 2020. Mr S was in receipt of services from Central North West London NHS Trust.