Source · Investigations in the NHS

An independent investigation into the care and treatment of SV

Midlands Published 01 Sep 2025 Investigator Niche

NHS England Midlands Region, commissioned Niche Health and Social Care Consulting Ltd to carry out an independent investigation into the care and treatment of mental health service user SV following a domestic homicide in 2017. The main purpose of an independent investigation is to ensure that mental health care-related homicides are investigated in such a way that lessons can be learned effectively to prevent recurrence. The investigation process may also identify areas where improvements to se

Acceptance status

Per recommendation

No Response Published

Total recommendations

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

9 total

Recommendation

The links between the mental health care provided by the GP (during depot clinics) and the overall mental health care plan were weak. There was a lack of information sharing about risk and challenges. The Integrated Care Board, GP practices … Read more

Recommendation

There is no policy guidance about discharge from community mental health services. The Trust should provide clear policy guidance and protocols for discharge processes. They should include references to the Section 117 MHA aftercare policy.

Recommendation

Quality assurance systems in the Trust did not identify that care plans were not recovery-focused or outcome-based. The Trust must develop systems that provide robust oversight of the quality of care plans and interventions. This should include processes which: • … Read more

Recommendation

Quality assurance systems in the Trust did not identify the inadequacies of the risk assessments in this case. • The Trust must review its approach to clinical risk assessment and management, in particular to ensure that it has set out … Read more

Recommendation

Approaches to MDT meetings and the documentation of discussions were not standardised across community mental health teams. This meant that key risk information was not readily available at outpatient clinics, and medical staff were not always given the opportunity to … Read more

Recommendation

There was a lack of focus on the experiences of family and carers. There was no discussion of what the role of carer meant and a critical lens was used to view interactions. The Trust must review and clearly set … Read more

Recommendation

The Trust policy uses duty of candour and Being Open interchangeably. The policy should be revised to clarify that they are distinct and have different accountabilities and responsibilities.

Recommendation

There was no evidence that care provided for a service user with chronic psychosis was in line with the NICE clinical guideline, Psychosis and Schizophrenia in Adults. The Trust must ensure that best practice guidance for the prevention and management … Read more

Recommendation

We suggest that the Trust reviews the learning from this investigation to ensure that the transformation and the Patient, Service User and Carer Involvement and Engagement Strategy cover the issues highlighted.