Investigations in the NHS

DO who committed a homicide in 2013. DO 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 DO who committed a homicide in 2013. DO was in receipt of services from South London and Maudsley NHS Foundation Trust and NHS Croydon CCG.

This is the Independent Investigation into the care and treatment of Mr X .

Ms X and her son who died in September 2014. Ms X had received care from Berkshire Healthcare NHS Foundation Trust

This is the report of the independent investigation into the care and treatment provided to Ms X . The Investigation was asked to examine a set of circumstances associated with the death of Ms X and her son who died in September 2014. Ms X had received care from Berkshire Healthcare NHS Foundation Trust for a short time up until the month before her death.

This is the independent investigation report into the care and treatment of Mr S who committed a homicide in 2013. Mr S was in receipt of services from Central and North West London Trust.

This is the report of the independent investigation into the care and of Thomas.

This is the report of the independent investigation into the care and treatment of Mr X .

June 2016. At the time of the homicide Mr W was not in receipt of mental health services. He had previously received care and treatment from Lancashire Care NHS Foundation Trust

This is the report of the independent investigation into the care and treatment of Mr W . Mr W was convicted of the murder of Mr Dollery in June 2016. At the time of the homicide Mr W was not in receipt of mental health services. He had previously received care and treatment from Lancashire Care NHS Foundation Trust (community mental health services) and Inspire (substance misuse services). The independent investigation report has also been published by: An action plan has been published by Lanc

Mr E who committed a homicide in 2012. Mr E 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 E who committed a homicide in 2012. Mr E 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 S , a mental health service user in Surrey The trust’s action plan is also available.

L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust

This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust.

Harrogate Health Care NHS Trust

This is the independent investigation into the care and treatment of mental health service user MB . At the time of the offence MB was receiving mental health services provided by Harrogate Health Care NHS Trust. The associated assurance report has been published by Tees, Esk and Wear Valleys NHS Foundation Trust which is the current provider of these services in Harrogate. NHS England has also published an assurance statement into this case.

Mr B who committed a homicide in 2012. Mr B 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 B who committed a homicide in 2012. Mr B was in receipt of services from South London and Maudsley NHS Foundation Trust.

Sefton Safer Communities Partnership and Mersey Care NHS Foundation Trust

This is the joint Domestic Homicide and Independent Investigation in to the care and treatment of ‘Dean’ , commissioned by Sefton Safer Communities Partnership and NHS England (North). The associated action plans have been published by Sefton Safer Communities Partnership and Mersey Care NHS Foundation Trust.

Mr G who committed a homicide in 2012. Mr G was in receipt of services from Camden and Islington NHS Foundation Trust

This is the independent investigation report into the care and treatment of Mr G who committed a homicide in 2012. Mr G was in receipt of services from Camden and Islington NHS Foundation Trust.

Hertfordshire Partnership University NHS Foundation Trust

Patient Mr O killed Ms M and was convicted of her murder. He was in contact with mental health services delivered by Hertfordshire Partnership University NHS Foundation Trust and was previously a patient of Avon and Wiltshire Mental Health Partnership NHS Trust. This independent review was undertaken alongside a Multi Agency Partnership Review into the death of Ms M in December 2015 which was commissioned by the Hertfordshire Adult Safeguarding Board. In 2019, NHS England commissioned an assuran

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

Tees, Esk and Wear Valleys NHS Foundation Trust

This is the independent investigation into the care and treatment of mental health service user Mr S . At the time of the offence Mr S was receiving mental health services provided by Tees, Esk and Wear Valleys NHS Foundation Trust. The associated action plan has been published by Tees, Esk and Wear Valleys NHS Foundation Trust. An independent external quality assurance review (published November 2019) can be viewed here.

This is the executive summary of an independent investigation report into the care and treatment of Patient A and Patient B. An action plan has been published by Cygnet Health Care and can be found on the their website .

Mr J who committed a homicide in 2014. Mr J 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 J who committed a homicide in 2014. Mr J was in receipt of services from South London and Maudsley NHS Foundation Trust.

Miss B was convicted of murder in December 2015. At the time of the homicide Miss B was receiving care and treatment from Rotherham, Doncaster and South Humber NHS Foundation Trust

This is the independent investigation report into the care and treatment of Miss B. Miss B was convicted of murder in December 2015. At the time of the homicide Miss B was receiving care and treatment from Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH). An action plan has been published by RDaSH and can be found on the their website .

· Verita

This is the Independent Review undertaken on behalf of Stockport Safeguarding Children Board and NHS England in to the death of Child D. The Chair of Stockport Safeguarding Children Board took the decision to convene a serious case review in Sept 2015 and commissioned an independent author. NHS England, North Region commissioned an independent review into the care and treatment of the Child D’s father. The Verita team authored Chapter 11 of this report.

Tees Esk and Wear Valleys NHS Foundation Trust

This is the independent investigation into the care and treatment of mental health service users (F and Maureen) in County Durham. F and Maureen were patients on Picktree Ward, a mental health service for older people (MHSOP) ward in the Bowes Lyon Unit at Lanchester Road Hospital, County Durham, provided by Tees Esk and Wear Valleys NHS Foundation Trust. On 19 May 2015, an incident occurred between Maureen and F which resulted in F pushing Maureen from behind resulting in her falling to the gro

Mr S . Mr S was convicted of the murder of Mrs S in 2014. At the time of the homicide Mr S was receiving care and treatment from Lancashire Care NHS Foundation Trust

This is the report of the independent investigation into the care and treatment of Mr S . Mr S was convicted of the murder of Mrs S in 2014. At the time of the homicide Mr S was receiving care and treatment from Lancashire Care NHS Foundation Trust. The report and associated action plans have been published by: Blackburn and Darwen CCG have published the report and will monitor the Lancashire Care NHS Foundation Trust action plan until fully implemented.

Solent NHS Foundation Trust

This is an Assurance Report reviewing progress made by Solent NHS Foundation Trust against the recommendations detailed in the Independent Investigation; relating to the care and treatment of Mr C, which was published in November 2015.