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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
Wales
Independent investigation: Caroline Evans, Llangadog, Camarthen (2003)
MH patient fatally shot victim then shot himself. Ind Inq 2005 – Previously sectioned for shotgun threat. Public protection not considered
37 recommendations Report PDF
North East and Yorkshire
Independent investigation: Caroline WillsAshley Wills, Cramlington, North-umberland (2000)
Paranoid Schizophrenic kills sister and her son in frenzied attack.. Ind Inq 2002
12 recommendations Report PDF
South West
Independent investigation: Carol Trethewey (Mrs S), St Austell, Cornwall (2000)
Depressive repeatedly and fatally stabbed wife. Ind Inq 2003, failings in care,got 3 yrs probation
4 recommendations Report PDF
East of England
Independent investigation: Carol Wetherley, Needham (2010)
Paranoid Schizophrenic slits mother’s throat claiming Jesus made him do it.. MH History
2 recommendations Report PDF
North East and Yorkshire
Independent investigation: Casey Kearney, Doncaster (2012)
Recent MH patient fatally stabs teenager. Drug History. Long MH history, asked to be sectioned, warned not to carry knives
21 recommendations Report PDF
London
Independent investigation: Catherine Hampshire, Gant’s Hill (1994)
MH patient fatally stabs wife wife 300 times in head and neck – failed to take meds. Ind Inq 1996
-1 recommendations Report PDF
South East
Independent investigation: Catherine Ogram, Aldershot (2002)
Schizophrenic fatally punched and stabbed his girlfriend. Long history of MI – clear warning signs beforehand
14 recommendations Report PDF
Wales
Independent investigation: Cerys Yemm, Argoed (2014)
Mentally ill man fatally batters young woman. Recently released from prison with lack of aftercare
10 recommendations Report PDF
South West
Independent investigation: Charles Taylor, Poole (2018)
Mentally disordered man fatally battered his step-grandfather
3 recommendations Report PDF
North West
Independent investigation: Chloe Fahey, Manchester (2003)
Fatally stabbed daughter 52 times – attacked partner day before. Ind Inq 2010 – recently released MH patient – family and school concerns ignored
48 recommendations Report PDF
Scotland
Independent investigation: Chloe Sutherland (8 mnths), Edinburgh (2015)
Post-natally depressed mother fatally smothers daughter. Unable to access care as baby ‘too old’
13 recommendations Report PDF
South East
Independent investigation: Chris Poole, Eastbourne (2012)
Mentally ill man fatally punches and kicks man
6 recommendations Report PDF
South East
Independent investigation: Chris Stones, Worthing (2005)
Paranoid Schizophrenic stabs father of two. Long MH history
-1 recommendations Report PDF
Midlands
Independent investigation: Christina Edkins, Birmingham (2013)
Paranoid schizophrenic fatally stabs schoolgirl. Many apparent failings in care
25 recommendations Report PDF
London
Independent investigation: Christoph Duclos, Mile End Tube (2002)
Psychotic pushed stranger into oncoming train. Ind Inq 2006. Personality disorder and dual diagnosis
5 recommendations Report PDF
East of England
Independent investigation: Christopher Edwards, Chelmsford prison (1994)
Schizophrenic homicide. Ind Inq 1998, Coonan (European Court HR case)
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: Christopher Ritchie, Durham (2020)
Paranoid schizophrenic fatally stabbed acquaintance. Diminished responsibility – indefinite hospital order
6 recommendations Report PDF
North East and Yorkshire
Independent investigation: Claire Wilson (& unborn baby), Grimsby (2009)
Mentally ill man fatally stabs pregnant stranger killing her and her unborn daughter. Prev. 3 inpatient stays after threatening to kill someone with knives
17 recommendations Report PDF
Northern Ireland
Independent investigation: Clara Joughlin, Isle of Man (1995)
MH patient attacks two daughters, killing younger one. Ind Inq 1997. Long MH history
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: Colin Anderson, Newcastle (2006)
Recently released mentally ill man (with depressive LD accomplice) batters man and throws him off tower block.. Recently released after psychotic episode. Ind Inq due.
20 recommendations Report PDF
South West
Independent investigation: Colin Beynon, Bristol (1995)
Schizophrenic batters father to death with hammer on home visit. Ind Inq 1997 found “string of errors”
-1 recommendations Report PDF
London
Independent investigation: Colin Greenway, Thamesmead (2013)
Psychotic man fatally batters and cuts throat of disabled man. Previous violence, not taking meds, long MH history
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: Colin Johnson, Sunderland (2004)
Paranoid schizophrenic kills former school friend with an axe.. long history of increasing MH problems. Family asked MH for help 83 times before incident.
-1 recommendations Report PDF
East of England
Independent investigation: Colin Ricketts, Laindon, Essex (2009)
Mentally ill man with paranoid delusions fatally stabs mother’s boyfriend
5 recommendations Report PDF
South West
Independent investigation: Cooper Johnson-Hicks (9 mths), St Blazey (2016)
Mentally disordered man fatally battered his young son and subsequently took his own life. Inquest found baby was unlawfully killed
2 recommendations Report PDF