Investigations in the NHS

Oxford Health NHS Foundation Trust

NHS England has published an independent investigation report into the treatment and care of ‘Mark’ , who killed his step-grandfather after moving from Nottinghamshire to Dorset in 2018. Action plans in response to the report’s recommendations have been published by:

This is the independent investigation into the care and treatment of Ms F in Cumbria, Northumberland, Tyne and Wear Foundation Trust. Cumbria, Northumberland, Tyne and Wear Foundation Trust has also published an assurance statement into this case.

Tees, Esk and Wear Valleys NHS Foundation Trust

Tees, Esk and Wear Valleys NHS Foundation Trust

Devon Partnership NHS Trust

NHS England has published a summary mental health homicide review into the care and treatment of Mr S , who was a service-user under the care of Devon Partnership NHS Trust. Mr S fatally stabbed his father at his parents’ home in 2019. Devon Partnership NHS Trust and NHS Devon have both published a joint action plan on their websites, in response to the report’s recommendations. The action plans are available at:

Tees, Esk and Wear Valleys NHS Foundation Trust

This is independent investigation into the care and treatment of Nadia in West Lane Hospital by Tees, Esk and Wear Valleys NHS Foundation Trust . Tees, Esk and Wear Valleys NHS Foundation Trust has also published an assurance statement into this case .

An independent investigation into the care and treatment of Emily at Tees, Esk and Wear Valleys NHS Foundation Trust

This is the the independent investigation into the care and treatment of Emily at Tees, Esk and Wear Valleys NHS Foundation Trust and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust . Tees, Esk and Wear Valleys NHS Foundation Trust has also published an assurance statement into this case .

An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust

This is the independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust. Tees, Esk and Wear Valleys NHS Foundation Trust has also published an assurance statement into this case .

This is the Joint Safeguarding Adult Review and Independent Mental Health Homicide Investigation, Ms G and Mr Q published on 10th November 2022.

This is the independent investigation report into the care and treatment of M published on 22nd November 2022.

East Kent Hospitals University NHS Foundation Trust · Dr Bill Kirkup CBE

Independent investigation into maternity and neonatal services at East Kent Hospitals University NHS Foundation Trust (QEQM Hospital, Margate and William Harvey Hospital, Ashford), covering care provided 2009–2020. Reviewed over 200 cases involving avoidable harm to mothers and babies. Found a culture of not listening to women, poor teamworking, and a trust focused on "looking good while doing badly". Published October 2022. Government accepted all recommendations July 2023.

Tees Esk and Wear Valley NHS Foundation Trust

This is the independent review of the investigation undertaken by Tees Esk and Wear Valley NHS Foundation Trust into the care and treatment of Mr H. Tees Esk and Wear Valley NHS Foundation Trust has also published an associated action plan which can be found here.

Joint Domestic Homicide Review and independent mental health homicide investigation in April 2019 in Northumberland. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

This is the Joint Domestic Homicide Review and independent mental health homicide investigation in April 2019 in Northumberland. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has also published an assurance statement into this case.

This is the independent investigation report into the care and treatment of Mr Y published on 5th October 2022. Mr Y was in receipt of services in South London.

Devon Partnership NHS Trust

NHS England has published a mental health homicide review into the care and treatment of Patient A , who was a service-user under the care of Devon Partnership NHS Trust. Patient A fatally stabbed a stranger outside a shopping centre in 2018. Devon Partnership NHS Trust and NHS Devon have both published a joint action plan on their websites, in response to the report’s recommendations. The action plans are available at:

An independent investigation into the dissolution of the independent midwifery provider One to One Midwives. One to One Final Report Appendices – August 2022 post One to One Midwives was an independent sector provider established in 2010 to provide maternity services to NHS-funded clients through a midwifery-led, community-based, ‘case loading’ model. One to One Midwives was one of a small number of similar businesses over the last ten years which aimed to bridge the gap between greater choice a