Investigations in the NHS

NHS England commissioned a limited scope independent review into patient safety concerns and governance processes related to the North East Ambulance Service. Chaired by Dame Marianne Griffiths DBE, the review considered the facts surrounding a number of individual cases, reviewed the processes surrounding coronial investigations and reviewed the seven previous investigations and reviews undertaken by the ambulance service to determine if they were sufficient to fully understand and resolve issu

The investigation was prompted by an incident in Birmingham in 2020 that resulted in: 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

Betsi Cadwaladr University Health Board

Betsi Cadwaladr University Health Board

University Hospitals Birmingham NHS Foundation Trust

University Hospitals of Morecambe Bay NHS Foundation Trust

These documents have also been published by: University Hospitals of Morecambe Bay NHS Foundation Trust NHS Lancashire and South Cumbria

Greater Manchester Mental Health NHS FT

This is the full report of the independent investigation report into the care and treatment of service user Mr E. Following an incident in February 2020 Mr E pleaded guilty to manslaughter on the grounds of diminished responsibility and is now an inpatient at a high secure hospital. At the time of the incident, Mr E was under the care of Greater Manchester Mental Health NHS FT . These documents have also been published by:

Norfolk and Suffolk NHS Foundation Trust

This report was commissioned by the trust and made twelve recommendations to improve the care and treatment of service users, and three recommendations to improve practice following a serious incident. The investigation was prompted by the death of an 84-year-old gentleman who had been walking his dog in a remote wooded area in Norfolk by a 23-year old man. At the time of the homicide the young man was not under the care of mental health services, but he had had three previous episodes of care p

Somerset NHS Foundation Trust

NHS England has published an independent investigation report into the care and treatment of Mr D , a newly-referred patient of mental health services in Somerset, who killed his neighbour in 2020. An action plan in response to the report’s recommendations has been published by Somerset NHS Foundation Trust. NHS England has also published a shared learning bulletin to distil the findings and lessons from the main investigation report.

Mersey Care NHS Foundation Trust

These are the full report and lessons learned bulletin of the independent investigation report into the care and treatment of service user Mr E. Following an incident in January 2019, Mr E was convicted of murder. At the time of the incident, Mr E was under the care of Mersey Care NHS Foundation Trust. These documents have also been published by:

The investigation resulted from the death of a 59 year-old woman in 2018 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. The way that mental health services are delivered in Herefordshire has changed since the incident in 2018 (please see here for more details). That’s wh

CAMHS provision at West Lane Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust

This is a system-wide independent investigation into concerns and issues raised relating to the safety and quality of CAMHS provision at West Lane Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust. Tees, Esk and Wear Valleys NHS Foundation Trust has also published an assurance statement on their website here.

Betsi Cadwaladr University Health Board

· National Guardian's Office

Mersey Care NHS Foundation Trust

These are the Executive Summary report and a Lessons Learnt bulletin of the independent investigation report into the care and treatment of service user Ben. Executive Summary report Lessons Learned bulletin Ben was convicted of manslaughter in January 2019. At the time of the homicide Ben was receiving care and treatment provided by Mersey Care NHS Foundation Trust. These documents have also been published by: