Source · Investigations in the NHS

An independent investigation into the care and treatment of Ms P

Midlands Published 01 Jan 2026 Investigator Niche Subject Ms P

Index summary

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

Recommendations

4 total
1 Addressed to: NHS Trust No Response Published

Link to recommendation 1

Recommendation · source text
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 and follow-up of key issues, and liaison with external agencies.
2 Addressed to: NHS Trust No Response Published

Link to recommendation 2

Recommendation · source text
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 Addressed to: NHS Trust No Response Published

Link to recommendation 3

Recommendation · source text
When physical health concerns are identified, a documented plan should be agreed to support the service user to access health services as needed.
4 Addressed to: NHS Trust No Response Published

Link to recommendation 4

Recommendation · source text
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.

Acceptance status

Per recommendation
No Response Published
4

Total recommendations
4
About this data

Acceptance status records the published response to each recommendation. Acceptance does not establish that an action has been completed.

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.