Investigations in the NHS

Leicestershire Partnership NHS Trust

The investigation was prompted by the death of a 92 year-old man in 2019 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. An Independent Investigation into the care and treatment of Tom Action Plan – Leicestershire Partnership NHS Trust

Published August 2022 This is the independent quality assurance review of the care and management of Mr F . South West Yorkshire Partnership NHS Foundation Trust

This is the independent quality assurance review of the care and management of Mr F . South West Yorkshire Partnership NHS Foundation Trust has also published an assurance statement into this case .

Norfolk and Suffolk NHS Foundation Trust

The independent assurance review provides an assessment of the implementation of the actions developed in response to recommendations from the independent investigation into the care and treatment of Mr K in Suffolk.

This is the report of the independent investigation into the care and treatment of a mental health service user Mr J in Kent. At the time of the homicide (2018), Mr J was under the care of the Early Intervention in Psychosis team at Kent and Medway NHS and Social Care Partnership Trust.

This is the independent investigation report into the care and treatment of Mr X published on 13th June 2022. Mr X was in receipt of services in South West London.

NHS England has published a Root Cause Analysis Investigation Report into the Death of Dr Julien Warshafsky . The focus of this case review is to explore opportunities for collective learning and identify actions that could be either considered or taken to minimise the risk of recurrence.

Greater Manchester Mental Health NHS Foundation Trust

An independent investigation into the care and treatment of Ms A This is the Executive Summary of the independent investigation report into the care and treatment of Ms A. Ms A was convicted of manslaughter in December 2020. At the time of the homicide Ms A was receiving care and treatment provided by Greater Manchester Mental Health NHS Foundation Trust. The Executive Summary has been published by: This is the Assurance Review for the actions taken by Greater Manchester Mental Health NHS Founda

Published May 2022 This is the extended executive summary of the independent investigation into the care and treatment of Mr G. South West Yorkshire Partnership NHS Foundation Trust

This is the extended executive summary of the independent investigation into the care and treatment of Mr G. South West Yorkshire Partnership NHS Foundation Trust has also published an assurance statement into this case.

This is the Joint Domestic Homicide Review and independent mental health homicide investigation in January 2019, West Cumbria. West Cumbria Community Safety Partnership has published an associated action plan which can be found here.

Devon Partnership NHS Trust

In 2013, NHS England (NHSE) assumed overarching responsibility for the commissioning of independent investigations into mental health homicides and serious incidents committed by patients being treated (or recently treated) for mental illness. Previously this responsibility had been held by the strategic health authorities. The purpose of publishing the findings and learning from this investigation some years after the event is to ensure that NHS England and NHS Improvement openly and transparen

This is the independent assurance review for Mr X published on 4th April 2022. Mr X was in receipt of services in South West London.

The Shrewsbury and Telford Hospital NHS Trust · Donna Ockenden

Independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, commissioned by the Secretary of State for Health and Social Care in 2017. Led by Donna Ockenden (senior midwife). Final report published 30 March 2022. Reviewed 1,486 families over 20 years (2000–2019), finding repeated failures in care involving three maternal deaths and multiple baby deaths and brain injuries. Identified a culture of not listening to women, poor teamworking, and failure to learn from adverse events. Made 15 Immediate and Essential Actions (IEAs) applicable to all NHS trusts, and 64 Local Actions for Learning specific to the trust. Government accepted all national recommendations on publication and committed £127m to maternity services improvement.

Published 30 March 2022 This is the extended executive summary of the independent investigation into the care and treatment of Mr G. Bradford District Care NHS Foundation Trust

This is the extended executive summary of the independent investigation into the care and treatment of Mr G. Bradford District Care NHS Foundation Trust has also published an assurance statement into this case.

University Hospitals of North Midlands NHS Trust

NHS England has published an independent investigation report into the care and treatment of Mr K , a patient of mental health services in Somerset, who killed another man in Honiton in June 2017. An action plan in response to the report’s recommendations has been published by Somerset Clinical Commissioning Group. NHS England subsequently published a quality assurance review to assess progress on the recommendations.

Published February 2022 This is the executive summary of the independent investigation into the care and treatment of Mr A. South West Yorkshire Partnership NHS Foundation Trust

This is the executive summary of the independent investigation into the care and treatment of Mr A. South West Yorkshire Partnership NHS Foundation Trust has also published an assurance statement into this case.

The investigation was prompted by the death of a 34 year-old man in 2017 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the investigation is to help the NHS and partners understand if there are lessons that could be learned that could prevent something similar happening in the future.

This is the independent investigation report into the care and treatment of Mr N published on the 10 th February 2022. Mr N was in receipt of services in West London.

This is the independent investigation report into the care and treatment of Mr N and Mr G published on 21st February 2022. Mr N and Mr G were in receipt of services in North London.