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Investigations in the NHS

896 investigations 6864 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 6,864 recommendations. 76% of investigations have extracted recommendations. 680 investigations have recommendations tracked.

Investigations

Click an entry for full report & recommendations
North East and Yorkshire
Independent investigation: Bernard Clark, Barnsley, Yorkshire
Paranoid Schizophrenic stabbed father.. Ind Inq (2004/3403) 2008. Previously sectioned for attempted murder. Ceased meds before killing
22 recommendations Report PDF
North East and Yorkshire
Independent investigation: Bertha Martin, Cleadon (2008)
Mentally ill woman fatally batters mother. Previously sectioned & violent, released without aftercare. Ind Inq 2014 NHS North
29 recommendations Report PDF
North East and Yorkshire
Independent investigation: Bethany Rae Fields, Huddersfield (2019)
Mentally disordered and coercive man fatally and repeatedly stabs friend. MH staff warned three times previously of his threats to kill
4 recommendations Report PDF
London
Independent investigation: Bianca ‘Kay’ Shepherd, Uxbridge (2015)
Paranoid schizophrenic fatally stabs housemate. Previous history of aggression and violence
4 recommendations Report PDF
East of England
Independent investigation: Boris Reavey, Bedford (2008)
Paranoid schizophrenic fatally stabs stranger three days after release from psych. hospital. long MH history had been inpatient 15 times
-1 recommendations Report PDF
East of England
Independent investigation: Brenda Horrod, Hickling, Norfolk (1995)
MH patient fatally batters, stabs and smothers wife day after leaving hospital. Ind Inq 1998, Armstrong
-1 recommendations Report PDF
South East
Independent investigation: Brenda Lindley, Northfleet (2007)
Mentally ill man fatally batters wife then kills himself
6 recommendations Report PDF
London
Independent investigation: Brian Cherry, Walthamstow (2004)
Mentally ill man killed victim, cut off both arms & one leg, fried brains. Later murdered Loudwell (qv) in Broadmoor. Ind Inq 2009. Had previously been released from secure hospital as no threat.
-1 recommendations Report PDF
Wales
Independent investigation: Brian Dodd, Prestatyn (2003)
Paranoid schizophrenic fatally and repeatedly (28 times) stabbed a stranger. V critical indep inq 2004, previously slashed strangers throat 1996. released 2000. Prev danger to others noted. Had stopped meds
22 recommendations Report PDF
East of England
Independent investigation: Brian Haynes, Peterborough (2008)
Mentally disordered man involved in fatal attack on inmate. Inq found poor care and missed opportunities
-1 recommendations Report PDF
South West
Independent investigation: Brian Kemp, Sidmouth (2013)
Psychotic man fatally stabs stranger. Deteriorating for months before
2 recommendations Report PDF
South West
Independent investigation: Brian Marsh, Swindon (2007)
Mentally ill man in frenzied fatal attack on stepfather, and attacks mother. Many failings – Preventable homicide
23 recommendations Report PDF
London
Independent investigation: Bridget MaclennanElizabeth Valad, Camden
Psychiatric patient killed and cut up bodies. Ind Inq 2005 Lengthy psych history, ind inq claimed ‘clinically normal’ at time of killings
-1 recommendations Report PDF
London
Independent investigation: Bryan Bennett, Newham (1994)
MH patient fatally stabbed victim more than 80 times. Ind Inq 1995 – previous violence
3 recommendations Report PDF
London
Independent investigation: Camille Remy (pregnant), Hackney (2006)
Paranoid Schizophrenic fatally and repeatedly stabbed stranger student.. Ind Inq. Released from hospital against medical advice. History of violence with blades
24 recommendations Report PDF
London
Independent investigation: Carla Thompson, Merton (1998)
MH homicide – prolonged and violent assault,. Ind Inq 2000
-1 recommendations Report PDF
London
Independent investigation: Carl Everson, Barking (2010)
Mental health patient batters man and fatally stabs him. Inq found many failings in care – had killed before. Ind inq, Wynchcombe, 2013
9 recommendations Report PDF
South West
Independent investigation: Carl James, Swindon (2007)
Schizophrenic fatally stabbed friend 6 times. Prev. threatened violence. Mother warned MH services
4 recommendations Report PDF
South East
Independent investigation: Carl Scott, Winchester
Schizophrenic man fatally battered and stabbed man
11 recommendations Report PDF
London
Independent investigation: Carmel Charles, Catford (2011)
Mentally ill man fatally stabs woman. MH history
6 recommendations Report PDF
London
Independent investigation: Carmelita Tulloch, Vauxhall, London (2006)
Paranoid schizophrenic stabbed a stranger seven times
23 recommendations Report PDF
North West
Independent investigation: Carole Dyson, Adlington (2014)
Mentally disordered man fatally strangles wife
11 recommendations Report PDF
North West
Independent investigation: Carol Houghton, Birkenhead (1998)
Schizophrenic fatally battered girlfriend around face and head.. Ind Inq 2001, Ceased meds, previously sectioned after stabbing
-1 recommendations Report PDF
Midlands
Independent investigation: Caroline Burningham, Welling-borough, Northants (1997)
Paranoid schizophrenic batters, sexually assaults and fatally strangles pregnant woman (stranger). Ind Inq 1999
-1 recommendations Report PDF
London
Independent investigation: Caroline Coates, Dalston (1997)
Mentally ill man repeatedly and fatally stabs woman. Ind Inq 2000
-1 recommendations Report PDF