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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
East of England
Independent investigation: Daniel Coleman, Norfolk (1996)
MH Homicide. Ind Inq 2001 Armstrong
-1 recommendations Report PDF
South East
Independent investigation: Daniel Quelch, Maidenhead, Berks (2007)
Paranoid Schizophrenic breaks into house and fatally and repeatedly stab stranger in front of his children. Long MH history – sectioned 2001 – not taking meds
9 recommendations Report PDF
North East and Yorkshire
Independent investigation: Darren Edeson, Leeds (2011)
Had told psych nurses months before she wanted to kill. Had told psych nurses months before she wanted to kill
6 recommendations Report PDF
London
Independent investigation: Darren Flynn, HMP Swaleside (2015)
Two mentally disordered prisoners repeatedly & fatally stabs fellow prisoner
2 recommendations Report PDF
South East
Independent investigation: Darren Lock, Newbury (2012)
Mentally ill man fatally stabs man
9 recommendations Report PDF
North East and Yorkshire
Independent investigation: David Burrows, Ravensthorpe, Yorks (2005)
MH Homicide w knife whilst out on bail after conviction for assault. Ind Inq, (2005/3404) 2007. Previous hist of violence. Suicide in jail
6 recommendations Report PDF
North West
Independent investigation: David Capseed, Liverpool (2019)
Mentally disordered man with schizophrenia fatally battered acquaintance. Convicted of murder
6 recommendations Report PDF
London
Independent investigation: David Donnelly, Woolwich (2003)
Mentally ill man fatally stabs mentally ill neighbour. Long MH history, previous sec 37/41 but discharged & not recalled when unwell
-1 recommendations Report PDF
London
Independent investigation: David Fairburn, Barking (2004)
Homicide by mentally ill. Ind Inq 2010 NHS
4 recommendations Report PDF
South East
Independent investigation: David Ford, Margate (2011)
Man with schizophrenia fatally attacks fellow hostel resident
4 recommendations Report PDF
North East and Yorkshire
Independent investigation: David Huitson, Newcastle (2001)
Schizophrenic stabbed victim who had given evidence against him in another stabbing case.. Ind Inq 2004 – history of previous violence.
-1 recommendations Report PDF
London
Independent investigation: David Kemp, Great Yarmouth (2008)
MH patient absconds from secure unit and murders stranger. Previous serious violence
17 recommendations Report PDF
North East and Yorkshire
Independent investigation: David Limb, Wath (2004)
MH Homicide (+ alcohol). Ind Inq (2004/680) 2008
5 recommendations Report PDF
London
Independent investigation: David Philips, London (1998)
MH homicide. Ind Inq 2000
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: David Turnbull, Co Durham (1997)
MH homicide. Ind Inq 2000
-1 recommendations Report PDF
South West
Independent investigation: Dawn Green, Newquay (2016)
Depressed man fatally strangles wife then kills himself
9 recommendations Report PDF
Wales
Independent investigation: Dean Shorney, Bargoed (2006)
MH patient fatally and repeatedly stabs victim.. Critical Ind Inq 2008. Known high risk of violence.
5 recommendations Report PDF
Midlands
Independent investigation: Debra Larn, Leicester (2006)
MH patient fatally stabbed neighbour and wounded another (PD). Ind Inq 2007. Long MH history with violence. Predictable & preventable. Warnings. Poor team working.
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: Denise Eckersley, Leeds (1999)
MH battered wife to death. Ind Inq 2003
-1 recommendations Report PDF
East of England
Independent investigation: Denise Palmacci, Bedfordshire (1996)
Mentally ill man fatally stabs ex-girlfriend after release from Psychiatric hospital. Ind Inq 1997 Price
-1 recommendations Report PDF
London
Independent investigation: Denis Finnegan, Richmond Park (2004)
Psychotic fatally stabbed stranger whilst released from secure unit by Psych.. Ind Inq 2006. Errors made. Previous history of stabbing strangers
1 recommendation Report PDF
East of England
Independent investigation: Deraye Lewis, Bletchley (2004)
MH patient fatally punches toddler. Critical Inq. Verita 2010. (Case G) – PD and substance abuse
4 recommendations Report PDF
North East and Yorkshire
Independent investigation: Derek Brotherton, Bradford (2004)
Paranoid Schizophrenic fatally stabs stepdad.. Ind Inq. (2004/1904) 2006. Turned away from hospital day before.
7 recommendations Report PDF
East of England
Independent investigation: Derek Salmon, Colchester (2002)
MH patient fatally and repeatedly stabbed her husband. Yes – Ind Inq
4 recommendations Report PDF
South East
Independent investigation: Derek Saxby, Folkestone (2004)
MH Patient with schizophrenia kills fellow hostel resident. Long MH history. (Ind Inq 2013, Verita)
2 recommendations Report PDF