Source · Investigations in the NHS

Investigations in the NHS

896 investigations 8078 recommendations 11 regions

Independent investigation reports and reviews commissioned by government or NHS bodies. Includes mental health homicide investigations, major maternity reviews, patient safety reviews, and other independent investigations into healthcare failures.

Coverage

By region & key findings

Investigations by region

Key findings

896 independent health investigations across 11 regions, producing 8,078 recommendations. 76% of investigations have extracted recommendations. 683 investigations have recommendations tracked.

Investigations

Click an entry for full report & recommendations
Sep 2019
East of England
An independent investigation into the care and treatment of a mental health service user (Tom) in Cambridgeshire – September 2019
Sally. He had a long and complex mental health history and had previously had contact with mental health services at Northamptonshire Healthcare NHS Foundation Trust
The findings of an independent investigation into the circumstances surrounding the care and treatment of Tom are published on this webpage. Tom was charged and convicted of the manslaughter by diminished responsibility of his wife Sally. He had a long and complex mental health history and had previously had contact with mental health services at Northamptonshire Healthcare NHS Foundation Trust and was in contact with Cambridgeshire and Peterborough NHS Foundation Trust at the time of the incide
7 recommendations Report PDF
Aug 2019
South West
Independent review into treatment and care provided by 2Gether NHS Mental Health Foundation Trust
X’ was an inpatient at 2Gether NHS Mental Health Foundation Trust. The 2Gether NHS Foundation Trust
This is the report of an investigation commissioned by NHS England into care and treatment of ‘X’. At the time of the homicide (2014), ‘X’ was an inpatient at 2Gether NHS Mental Health Foundation Trust. The 2Gether NHS Foundation Trust action plan is available here .
3 recommendations Report PDF Action Plan
Jul 2019
London
Independent investigation into the care and treatment of Mrs A and Miss B
Mrs A and Miss B, published on 03 July 2019. Mrs A and Miss B was in receipt of services from Oxleas NHS Foundation Trust
This is the independent investigation report into the care and treatment of Mrs A and Miss B, published on 03 July 2019. Mrs A and Miss B was in receipt of services from Oxleas NHS Foundation Trust.
17 recommendations Report PDF Action Plan
May 2019
North West
An independent investigation into the care and treatment of MN: Published May 2019
MN. MN was convicted of manslaughter in August 2017. At the time of the homicide MN was receiving care and treatment from Cheshire and Wirral Partnership NHS Foundation Trust
This is the report of the independent investigation into the care and treatment of MN. MN was convicted of manslaughter in August 2017. At the time of the homicide MN was receiving care and treatment from Cheshire and Wirral Partnership NHS Foundation Trust. The report has been published by: This is the Assurance Review of the actions taken by Cheshire and Wirral Partnership NHS Foundation Trust and NHS Cheshire CCG
9 recommendations Report PDF
May 2019
Midlands
Independent care and treatment review into the care and treatment provided to Mr AS
Patient Mr AS took his life in October 2013 following a long and complex history of mental health illness. The purpose of the review was to fully consider the care and treatment provided to Mr AS and to make recommendations for further action where appropriate.
4 recommendations Report PDF
May 2019
Midlands
Independent external quality assurance review following the independent investigation into the care and treatment of P in the West Midlands
P was charged with the murder of Christina in 2013. The independent External Quality Assurance Review was commissioned by NHS England to review progress against the recommendations and actions identified as part of the independent investigation which was published in June 2017. All future updates on progress will be published by the individual organisations concerned.
25 recommendations Report PDF
May 2019
Midlands
Independent external quality assurance review in respect of mental health service users Mr A and Mr B.
NHS England, to review the outcomes of the Birmingham and Solihull Mental Health NHS Foundation Trust
Patient Mr A was charged and convicted of murdering his mother on 3 July 2012. Patient Mr B was charged and convicted of murdering his mother on 20 July 2011. The independent External Quality Assurance Review was commissioned by NHS England, to review the outcomes of the Birmingham and Solihull Mental Health NHS Foundation Trust’s (BMHFT) internal review and the Birmingham Community Safety Partnership’s Domestic Homicide Review following the two homicides.
27 recommendations Report PDF Action Plan
May 2019
Midlands
Independent investigation into the care and treatment of Mr S in the North Midlands
Derbyshire Healthcare NHS Foundation Trust
Patient Mr S killed victim 1 and victim 2 and then committed suicide. He had been in contact with mental health services delivered by Derbyshire Healthcare NHS Foundation Trust.
3 recommendations Report PDF
May 2019
Midlands
Independent investigation into the care and treatment of Ms Z in the North Midlands
Derbyshire Healthcare NHS Foundation Trust
Patient Ms Z was convicted of manslaughter with diminished responsibility of the victim. She had previously been in contact with mental health services delivered by Derbyshire Healthcare NHS Foundation Trust.
Report PDF
Apr 2019
North East and Yorkshire
A Joint Domestic Homicide Review and independent mental health homicide investigation in April 2019 in Northumberland: Published October 2022
Joint Domestic Homicide Review and independent mental health homicide investigation in April 2019 in Northumberland. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
This is the Joint Domestic Homicide Review and independent mental health homicide investigation in April 2019 in Northumberland. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has also published an assurance statement into this case.
14 recommendations Report PDF
Apr 2019
South East
An independent investigation into the care and treatment of Darren by Isle of Wight NHS Trust: April 2019
Isle of Wight NHS Trust
This is the report of the independent investigation into the care and treatment of Darren by Isle of Wight NHS Trust .
12 recommendations Report PDF Action Plan
Apr 2019
South East
An independent review into the care and treatment of Mr D: April 2019
This is the report of the independent review into the care and treatment of Mr D who was convicted of murder in November 2017.
7 recommendations Report PDF
Apr 2019
London
Independent investigation into the care and treatment of Mr H
This is the independent investigation report into the care and treatment of Mr H who committed a homicide in 2014, published on 10 April 2019. Mr H was in receipt of services from South West London & St George’s NHS Mental Health Trust and Merton CCG.
9 recommendations Report PDF Action Plan
Feb 2019
South West
An independent investigation into the care and treatment of a mental health service user Mr M in Cornwall
Cornwall Partnership NHS Foundation Trust
NHS England has published a mental health homicide review into the care and treatment of Mr M, who was a service-user under the care of Cornwall Partnership NHS Foundation Trust. Both Mr M and his wife were found dead at home in March 2016. Cornwall Partnership NHS Foundation Trust, NHS Kernow Clinical Commissioning Group and Outlook South West have published the associated action plan on their websites. Following the report on Mr M, an independent quality-assurance review on implementation of i
9 recommendations Report PDF Action Plan
Feb 2019
London
Independent investigation into the care and treatment of Mr R
This is the independent investigation report into the care and treatment of Mr R who committed a homicide in 2012, published on 28 February 2019. Mr R was in receipt of services from South West London & St George’s NHS Mental Health Trust.
3 recommendations Report PDF Action Plan
Jan 2019
North East and Yorkshire
A Joint Domestic Homicide Review and independent mental health homicide investigation in January 2019, West Cumbria: Published May 2022
This is the Joint Domestic Homicide Review and independent mental health homicide investigation in January 2019, West Cumbria. West Cumbria Community Safety Partnership has published an associated action plan which can be found here.
28 recommendations Report PDF Action Plan
Dec 2018
North East and Yorkshire
An independent investigation into the care and treatment of Harry Bosomworth by Leeds and York Partnership NHS Foundation Trust and …
Leeds and York Partnership NHS Foundation Trust
This is the report of the independent investigation into the care and treatment of Harry Bosomworth.
21 recommendations Report PDF
Dec 2018
North West
An independent investigation into the care and treatment of Mr L: Published 5 December 2018
This is the report of the independent investigation into the care and treatment of Mr L.
2 recommendations Report PDF
Nov 2018
North West
An independent investigation into the care and treatment of mental health service user L in Greater Manchester : Published 28 …
Greater Manchester Mental Health NHS Foundation Trust
This is the report of the independent investigation into the care and treatment of L. This is the Assurance Review of the actions taken by Greater Manchester Mental Health NHS Foundation Trust and Pennine Care NHS Foundation Trust , 12 months after publication of the independent investigation report.
6 recommendations Report PDF
Nov 2018
North East and Yorkshire
An independent investigation into the care and treatment of MS: Published 14 November 2018
This is the report of the independent investigation into the care and treatment of MS. Assurance statements and/or reports have been published by:
5 recommendations Report PDF
Nov 2018
North East and Yorkshire
An independent investigation into the care and treatment of Ms K: Published 7 November 2018
This is the report of the independent investigation into the care and treatment of Ms K. Assurance statements and/or reports have been published by:
6 recommendations Report PDF
Nov 2018
London
Independent investigation into the care and treatment of Mr J
Mr J who committed a homicide in 2014. Mr J was in receipt of services from East London NHS Foundation Trust
This is the independent investigation report into the care and treatment of Mr J who committed a homicide in 2014. Mr J was in receipt of services from East London NHS Foundation Trust and Newham CCG.
18 recommendations Report PDF Action Plan
Oct 2018
South East