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Investigations in the NHS

896 investigations 8078 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 8,078 recommendations. 76% of investigations have extracted recommendations. 683 investigations have recommendations tracked.

Investigations

Click an entry for full report & recommendations
London
Independent investigation: Geraldine Sureda(Mrs S), Mitcham Park, Merton (2000)
MH patient kills mother whilst on w/e leave from Springfield psych.hospital, Tooting. Ind Inq 2006 found catalogue of errors
36 recommendations Report PDF
London
Independent investigation: Gerry Fairall, Kilburn, London (2006)
Schizophrenic fatally knifed stranger and attacked another
8 recommendations Report PDF
South East
Independent investigation: Gilbert McCallum, Dover (2001)
Man with MH problems killed man. Ind Inq 2005
10 recommendations Report PDF
East of England
Independent investigation: Gillian PhilippsDavid Oakes, Stansted Mountfitchet (2015)
Mentally ill man fatally attacks mother and her partner, weeks after release from prison. Long MH history – subsequently murdered in prison
5 recommendations Report PDF
South West
Independent investigation: Gino Nelmes, Bristol (2012)
Paranoid schizophrenic fatally stabs friend 18 times with samurai sword. Prev. history of violence; released from secure unit days before assault
13 recommendations Report PDF
London
Independent investigation: Gita Suri, Greenwich (2018)
Mentally ill man repeatedly and fatally stabs co-resident
23 recommendations Report PDF
South East
Independent investigation: Gordon Stalker, Brighton (2010)
Paranoid schizophrenic repeatedly and fatally stabs neighbour believing him to be a witch stealing his soul. History of increasingly erratic and threatening behaviour. Inq found death was preventable.
1 recommendation Report PDF
East of England
Independent investigation: Graham Rayner, Tavenham, Norfolk (2006)
Paranoid schizophrenic decapitates victim with axe and hides body in boot of car. Long MH history. prev. violence. Stopped meds. Inq said Preventable.
7 recommendations Report PDF
Midlands
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995)
Psychotic fatally stabbed mother and step brother, a month after release from psych unit. Ind Inq 1996
56 recommendations Report PDF
Wales
Independent investigation: Gwen Poole, Llanbradach, Caerphilly (2009)
Deluded Schizophrenic mentally ill man fatally stabs pensioner (stranger). Indefinite hospital order
-1 recommendations Report PDF
Midlands
Independent investigation: Halimah Ahmed, Derby (2007)
Psychiatric patient smothers girl then hangs himself. Ind Inq 2010. & Coroners report. Prev violence – Known risk – tried to section 3 times but no S/W
9 recommendations Report PDF
North East and Yorkshire
Independent investigation: Halina Szymczuk, Ashington, North-umberland (1995)
Mentally ill man fatally stabbed neighbour (murdering Mother-in law 1976).. Ind Inq 1996
-1 recommendations Report PDF
London
Independent investigation: Hamidi HamidullahKhizer Hayat, Tulse Hill (2006)
Paranoid Schizophrenic firebombs ‘non-christian’ shop killing two workers. Ind Inq 2010. Previous history of violence, released from Psych hosp by MHT
18 recommendations Report PDF
North West
Independent investigation: Harry Johnstone, Oldham (1994)
MH patient bludgeons man to death. Ind Inq 1997
-1 recommendations Report PDF
South East
Independent investigation: Harry Messenger, Faversham (2017)
Mentally disordered man repeatedly and fatally batters neighbour with a hammer. Convicted of murder
7 recommendations Report PDF
North West
Independent investigation: Harry Upton, Culcheth, Warrington (2002)
Former MH patient fatally stabs pensioner during burglary. Ind Inq 2005
8 recommendations Report PDF
North West
Independent investigation: Hazel Horner, Lower Darwen (1996)
MH patient kills wife and self a day after discharge from psych unit.. Critical Ind Inq 1997
-1 recommendations Report PDF
North West
Independent investigation: Heath Rowson, Manchester (1998)
Delusional paranoid schizophrenic batters flatmate to death. Critical Ind Inq – 2001
-1 recommendations Report PDF
North East and Yorkshire
Independent investigation: Helen Hay, Sheffield (2004)
MH homicide of stranger after altercation in nightclub. Ind Inq (2004/1964) 2008
3 recommendations Report PDF
London
Independent investigation: Henrietta Leane, Cricklewood (1997)
MH patient poured petrol in living room and struck match, killing mother. Ind Inq 2001
-1 recommendations Report PDF
London
Independent investigation: Hugh McCaffrey, Willesden
Mentally ill woman fatally stabbed partner through the heart. Ind Inq 2002 – got 3 years
42 recommendations Report PDF
North West
Independent investigation: Ian Dollery, Lytham St Annes (2015)
Paranoid schizophrenic fatally stabs stranger. Long history of mental illness and violence.Poor investigation.
3 recommendations Report PDF
North East and Yorkshire
Independent investigation: Ian LawsonSimon Richardson, Sunderland
Paranoid schizophrenic fatally and repeatedly stabbed Lawson, then fatally attacked Richardson with a Razor.. Ind Inq 2007
-1 recommendations Report PDF
North West
Independent investigation: Irene Lythgoe, Atherton (1998)
Paranoid schizophrenic kills mother with hammer & then attacks father.. Ind Inq 2000
-1 recommendations Report PDF
London
Independent investigation: Ivy Newman, Tower Hamlets (1998)
Mentally ill man ‘savagely kills’ his grandmother and rapes corpse. Ind Inq 2002
-1 recommendations Report PDF