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An independent investigation into the care and treatment of Ms P

Midlands Published 01 Jan 2026 Investigator Niche Subject Ms P

This investigation relates to the care and treatment of an adult female (referred to as Ms P in the document) who was known to local mental health services prior to her conviction for homicide in 2023. The subsequent investigation, carried out by Niche consulting, identified four recommendations, which are set out as Critical Learning Points in the shared learning bulletin . These recommendations relate to Individual practice; Governance focussed learning; Board assurance; and System learning po

Report PDF NHS England Source
Jump to 4 recommendations

Acceptance status

Per recommendation
No Response Published
4
Total recommendations
4
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

4 total
1 NHS Trust No Response Published
Recommendation
Every service user should have a primary contact responsible for oversight of their care during periods of crisis. Dependent on the service user’s level of need, this should extend to developing a care plan coordinating all aspects of care, management … Read more
2 NHS Trust No Response Published
Recommendation
Risk assessments for community-based service users should be up to date and subject to regular review. A risk management plan should reflect the detail of the risk assessment.
3 NHS Trust No Response Published
Recommendation
When physical health concerns are identified, a documented plan should be agreed to support the service user to access health services as needed.
4 NHS Trust No Response Published
Recommendation
Trusts need to ensure there are effective communication pathways available to partner agencies and third sector organisations to ensure prompt contact and information sharing for all service users. This should include an agreed central contact pathway for matters requiring escalation. Read more