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An independent investigation into the care and treatment of Adult 1

South West Published 01 Jan 2026

Published January 2026 The executive summary of an independent investigation into the care and treatment given to Adult 1, a mental health service user, who fatally attacked a family member, Adult 2, in 2021. This accompanies the learning bulletin above. Click here for the executive summary.

Report PDF NHS England Source
Jump to 13 recommendations

Acceptance status

Per recommendation
No Response Published
13
Total recommendations
13
About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

13 total
Recommendation 1 The Trust No Response Published
Recommendation
Information given to relatives about the MHA and the Nearest Relative (NR) rights Adult 2 was not told her rights as the NR, specifically that she could formally request that the local authority consider the patient’s case with a view … Read more
Recommendation 10 The Trust and the Council No Response Published
Recommendation
Application of the Mental Capacity Act (MCA) Adult 1 was taken to hospital under the MCA and remained in general hospital for an extended period of time (greater than 10 hours) without formal assessment under either the MCA or the … Read more
Recommendation 11 The Trust and Ambulance Trust 1 No Response Published
Recommendation
Application of the MCA On several occasions Trust staff assessed Adult 1 and found him to be lacking capacity. Ambulance Trust 1 also found him to be lacking capacity on one occasion. But the assessments were not documented in accordance … Read more
Recommendation 12 The Integrated Care Board (ICB), the Council and the Trust No Response Published
Recommendation
System management of safeguarding referrals Safeguarding referrals were not robustly followed up when passed back through primary care and we were unable to determine how the Council assured itself that duties conducted on its behalf were completed as required. The … Read more
Recommendation 13 The Trust No Response Published
Recommendation
Being open and involving families in serious incidents There was a lack of clarity about the implementation of new policies and processes in the transition to PSIRF this meant the process was not transparent for families, which led to great … Read more
Recommendation 2 The Trust (or the Council if MHA AMHP assessments are no longer covered by a Section 75 agreement) No Response Published
Recommendation
MHA and NR rights Adult 2’s right to request that the local authority consider the patient’s case with a view to making an application for admission to hospital was dismissed or not given due consideration. The responses to her requests … Read more
Recommendation 3 The Trust No Response Published
Recommendation
MHA and family involvement Concerns raised by family and other professionals were not given due consideration and were not responded to as requests for MHA assessment. The Trust must ensure that policy guidance includes the management of requests by family … Read more
Recommendation 4 The Trust No Response Published
Recommendation
MHA and urgent requests for assessment The family was left unsupported and without access to mental health support services over a weekend. There was an over-reliance on emergency services responding if a crisis occurred before the planned assessment. The Trust … Read more
Recommendation 5 The Trust No Response Published
Recommendation
MHA assessments and documentation The crisis team did not record their rationale for not completing an MHA assessment at home. Recording this would have ensured practice was in accordance with the least restrictive principles of the MHA. The Trust must … Read more
Recommendation 6 The Trust No Response Published
Recommendation
Section 17 leave standards There is no evidence of a risk assessment being carried out before Section 17 leave was granted. Section 17 leave was not always recorded correctly. The Trust must ensure that risk assessments at Hospital 2 are … Read more
Recommendation 7 The Council, The Trust No Response Published
Recommendation
MHA and involving the NR at detention and discharge There is no record of information being provided to the NR about Adult 1’s detention and discharge. The Council must ensure that the NR is provided with information about a patient’s … Read more
Recommendation 8 The Trust No Response Published
Recommendation
Involving families in assessments and care planning Neither the inpatient team nor the early intervention team (EIT) clinicians sought out family views, even when direct representations were made to the service by family members. The Trust must ensure that Hospital … Read more
Recommendation 9 The Trust No Response Published
Recommendation
Discharge standards There was no post-discharge follow up from Hospital 2, which contravenes policy. The Trust must ensure that when patients are discharged from hospital, post-discharge follow up is conducted in accordance with Trust policy and national guidance. Read more