Investigations in the NHS

Publication date 7 November 2023. NHS England has published an independent investigation report into the care and treatment of ‘JW’ , who killed an employee at the accommodation where he was staying in December 2020.

The findings of an independent investigation into the circumstances surrounding the care and treatment of James are published on this webpage. James killed his long-term girlfriend in December 2017. He had been a patient of North Essex Partnership Trust (NEPT), now Essex Partnership University Trust (EPUT) since 2000. A joint Independent Investigation and Domestic Homicide Review has taken place and both reports are available below: Essex Partnership University Trust, which is cited in the indep

This investigation was prompted by the death of a nine-year-old boy in 2014 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 understand if lessons can be learned that could prevent something similar happening in the future.

This is an independent external quality assurance review into the care and treatment of Mr M , a mental health service user in Sussex.

Mr Z, published on 8 th October 2020. Mr Z was in receipt of services from West London NHS Trust

This is the independent investigation report into the care and treatment of Mr Z, published on 8 th October 2020. Mr Z was in receipt of services from West London NHS Trust.

Mr J, published on 25 August 2020. Mr J was in receipt of services from South London and Maudsley NHS Trust

This is the independent investigation report into the care and treatment of Mr J, published on 25 August 2020. Mr J was in receipt of services from South London and Maudsley NHS Trust.

· Baroness Julia Cumberlege

Independent review commissioned by the Secretary of State for Health and Social Care in 2018 to examine how the healthcare system responded to patients harmed by three medical interventions: hormone pregnancy tests (Primodos), sodium valproate (epilepsy drug causing birth defects), and pelvic mesh implants. Led by Baroness Julia Cumberlege. Published July 2020. Found the healthcare system to be "disjointed, siloed, unresponsive and defensive". Made 9 strategic recommendations and 50 Actions for Improvement. Government rejected recommendations 3 and 4 (redress and compensation), accepted or accepted in principle the remainder.

Mr P in Dorset NHS England has published an independent investigation report into the care and treatment of a Dorset Healthcare University NHS Foundation Trust

NHS England has published an independent investigation report into the care and treatment of a Dorset Healthcare University NHS Foundation Trust patient who killed another man in Poole in August 2016. Action plans in response to the report’s recommendations have been published by: Dorset Healthcare University NHS Foundation Trust Dorset Clinical Commissioning Group Cornwall Partnership NHS Foundation Trust Bournemouth, Christchurch & Poole Safeguarding Adults Board (BCPSAB) commissioned a supple

Findings are published today of an independent investigation into the circumstances surrounding the care and treatment of Mr P, a mental health service user in Essex . Sincerest sympathies are offered to all the people who have been affected by this tragic event. Mr P killed Mrs H and Mr F at his mother’s address in Essex on 22 July 2015. Mr P was convicted of the murder of the two victims, who were his mother and her friend, and received a life sentence in May 2016. NHS England – East of Englan

David. At the time of his death David was receiving care and treatment from North West Boroughs Healthcare NHS Foundation Trust

An independent investigation into the care and treatment of David. This is the executive summary of the independent investigation report into the care and treatment of David. At the time of his death David was receiving care and treatment from North West Boroughs Healthcare NHS Foundation Trust. The Executive Summary and associated action plans have been published by: Links to action plans are included and these will continue to be monitored for progress. North West Boroughs Healthcare NHS Found

This is the report of the independent investigation into the care and treatment of a mental health service user A in NAViGO. An independent investigation assurance review (published June 2021) can be viewed here.

This is the report of the independent investigation into the care and treatment of mental health service user Mr M This published report includes: Mr M was convicted of the murder of a man in October 2017 whilst under the care of the Thomas project in Salford. The Thomas project provides a range of recovery focused services through detox and residential rehabilitation into community-based provision

Rotherham Doncaster and South Humber NHS Foundation Trust

This is the abridged executive summary of the independent investigation into the care and treatment of Jack. An independent quality assurance review (published August 2021) can be viewed here.

Southern Health NHS Foundation Trust

This is a report of the independent investigation into the care and treatment of Mr CD who was convicted of murder on 8 March 2016. Mr CD had received mental health and substance misuse services provided by Southern Health NHS Foundation Trust (SHFT) on several occasions between 2011 and September 2014. On the day of the homicide (20 March 2015) Mr CD had received substance misuse services provided by Solent NHS Trust.

This is an independent investigation into the care and treatment of Mr K , a mental health service user in Sussex.

The Learning Document from the independent investigation into the circumstances surrounding the care and treatment of Mr Q are published on this webpage:

Mr N was released from prison whilst detainable, but no suitable bed could be found. Mr N approached a policeman saying he was hearing voices telling him to kill people. The policeman took him to the local Emergency Department where he spent two days waiting for a bed. He was transferred to an Enhanced Care Ward and placed in seclusion, before his transfer into higher secure services after a couple of weeks. This was a near miss and investigated due to the potential for learning across systems.

Greater Manchester Mental Health NHS Foundation Trust

This is the report of the independent investigation into the care and treatment of a mental health service user (Mr A). Mr A was arrested and charged with murder in October 2017 and was later found guilty of manslaughter. Mr A was sentenced to an indefinite hospital order to treat his mental illness and has been detained in a secure hospital. This report and associated action plan has been published by: An action plan has been published by Greater Manchester Mental Health NHS Foundation Trust an

Mr B and Ms A, published on 13 November 2019. Mr B and Ms A were in receipt of services from Central and North West London NHS Foundation Trust

This is the independent investigation report into the care and treatment of Mr B and Ms A, published on 13 November 2019. Mr B and Ms A were in receipt of services from Central and North West London NHS Foundation Trust

To ensure that NHS England continues to commission high quality independent investigations that influence and support system wide development and improvement, NHS England commissioned an external review of all Independent Investigations following Mental Health Homicides (IIMHH) and the national governance arrangements underpinning this work. The review considered investigations undertaken between 2013 – 2017. NHS England have accepted the report findings and have developed an action plan which i

University Hospitals of Morecambe Bay NHS Foundation Trust

The purpose of this important investigation is to gain a full understanding of clinical and patient outcomes as the result of care delivered by the Trust’s Urology Service. The Investigation has identified areas for learning, as well as the identification of good practice, to ensure that a recurrence of the same or similar issues will be avoided in the future. Final Independent Investigation Urology Report – University Hospitals of Morecambe Bay NHS Foundation Trust Final Independent Investigati

This is the report of the independent investigation into the care and treatment of two mental health service users Mr A and Mr O. This is the Independent Quality Assurance Review of Mr A and Mr O following an investigation into the care and treatment of Mr A and Mr O. Published 3 August 2021.

This independent investigation arises from the murder of Russell, 37, on 13 June 2013. Mr K admitted manslaughter on the grounds of diminished responsibility and was detained indefinitely under the Mental Health Act.