Investigations in the NHS

THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

· Dr Hilary Cass

Independent review commissioned by NHS England and NHS Improvement in 2020, led by Dr Hilary Cass (retired consultant paediatrician, former President of the RCPCH). Published April 2024. Examined gender identity services for children and young people provided by GIDS at the Tavistock and Portman NHS Foundation Trust. Found services had expanded rapidly without an evidence base; poor clinical governance; inadequate follow-up of patients; and an unclear rationale for puberty blocker prescribing. Made 32 recommendations. NHS England accepted all 32. GIDS closed March 2024 and was replaced by two new regional services.

The investigation resulted from the death of a woman and her male child in 2021 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.

This document has also been published by:

Betsi Cadwaladr University Health Board

Greater Manchester Mental Health NHS Foundation Trust

Final report This is the final report of the Independent Review into the care and treatment provided by Greater Manchester Mental Health NHS Foundation Trust, following failings within the trust’s services, reported at the Edenfield Centre, and the failure within the organisation to escalate concerns and mitigate against patient harm. This report was commissioned by NHS England following concerns raised by patients, their families, and staff, some of which were presented through the media. This

This is the independent investigation report into the care and treatment of Mr D published on 2 November 2023.

This is the independent investigation report into the care and treatment of AB published on 18th October 2023.

Betsi Cadwaladr University Health Board

University Hospitals Birmingham NHS Foundation Trust

York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust

NHS South Yorkshire commissioned an independent investigation into the death of Yusuf and the care and treatment he received from his first contact with health services on 15 November 2022 . The report makes a number of recommendations for organisations involved in his care and treatment which, while they would not have changed the course of events for Yusuf, should be implemented to ensure there is learning from this case. The independent report can be viewed here. The Rotherham NHS Foundation

The investigation resulted from the death of a 87 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.

Betsi Cadwaladr University Health Board

Mr A , who was a service-user under Avon and Wiltshire Mental Health Partnership NHS Foundation Trust

This review should be read in conjunction with the report below, ‘Multi-agency systems review to identify the learning following five homicides in Devon (2018-2019); with a focus on mental health care and management in custody’ NHS England has published a mental health homicide review into the care and treatment of Mr A , who was a service-user under Avon and Wiltshire Mental Health Partnership NHS Foundation Trust, Devon Partnership NHS Trust and Cygnet Health Care between June 2016 and Decembe

This review should be read in conjunction with the report above, ‘An independent investigation into the care and treatment of Mr A in Devon’. NHS England has published a review looking at areas of concern following a total of five homicides in Devon in 2018 and 2019 . Three involved Mr A (above). The other two led to separate mental health homicide reviews, involving Patient A and Mr S, which have already been published (below). However, the primary focus of this review is on the learning from t

This document has also been published by:

Lancashire and South Cumbria NHS FT

These documents represent Part A and Part B of the full report for the independent investigation of the care and treatment of Mr X and the Lancashire Pathway Review. Following an incident in 2019, Mr X was charged with murder. Consequently, he was convicted of manslaughter and given a life sentence. He is currently detained in a high secure mental health hospital. At the time of the incident, Mr X was under the care of Lancashire and South Cumbria NHS FT. In November 2020, NHS England commission