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Mental Health Investigation

Independent investigations into the care and treatment of mental health service users

779 investigations 606 with recs 5,758 total recs 117 action plans

Investigations

Page 23 of 32
South West
Independent investigation: William Moss, Newquay (2007)
Schizophrenic repeatedly and fatally stabbed friend. Many failings – serious incident was ‘foreseeable’
14 recommendations Report PDF
North East and Yorkshire
Independent investigation: William Taylor, Cleveland (1995)
Psychotic MH patient fatally stabs father.. Ind Inq 1996
-1 recommendations Report PDF
London
Independent investigation: WPC Nina Mackay, Stratford, London (1997)
Paranoid schizophrenic fatally stabs WPC. Ind Inq 1999
-1 recommendations Report PDF
Midlands
Independent investigation: Zafar Iqbal, Nottingham (2000)
Detained paranoid schizophrenic leaves hospital without permission and kills brother in law. Ind Inq 2005
-1 recommendations Report PDF
London
Independent investigation: Zaki Oettinger, Croydon (2013)
Severely depressed mother kills herself and young son at railway station
12 recommendations Report PDF
May 2026
North West
An Independent Investigation into the adequacy of previous hospital-level investigations into Consultant Surgeon A: Published May 2026
Final report This is the final report of the Independent Investigation into the adequacy of previous hospital-level investigations into the clinical practice and leadership of Consultant Surgeon A, to determine whether further action is …
10 recommendations Report PDF
Apr 2026
East of England
An independent investigation into the care and treatment of Sam in Essex
· Niche
NHS England East of England Region and Midlands Region, commissioned Niche Health and Social Care Consulting Ltd (Niche) to carry out an independent investigation into the care and treatment of mental health service user, …
5 recommendations Report PDF Action Plan
Feb 2026
Midlands
Independent investigation of the care and treatment of Mr N
This document provides an overview of key findings from an independent investigation into the NHS care of a young man (Mr N) who killed a close relative. The subsequent investigation, carried out by Psychological …
6 recommendations Report PDF
Jan 2026
Midlands
An independent investigation into the care and treatment of Ms P
· Niche
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 …
4 recommendations Report PDF
Jan 2026
North East and Yorkshire
An independent investigation into the care and treatment of Mr P: Published January 2026
This is the executive summary of the independent investigation into the care and treatment of Mr P.
8 recommendations Report PDF
Jan 2026
South West
An independent investigation into the care and treatment of Adult 1
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. …
13 recommendations Report PDF
Nov 2025
East of England
Independent investigation into NHS mental health care of ‘X’
This Mental Health Homicide Review (MHHR) has been commissioned by NHS England regarding person ‘X’ who had been in contact with mental health services. X died from a fall from a height. X’s wife, …
4 recommendations Report PDF Action Plan
Oct 2025
East of England
Independent investigation into the care and treatment received by Mr B
The aim of this report is to help improve the delivery of care for people who are at risk of self-harm. Mr B was a 50-year-old man who had been living with secondary progressive …
7 recommendations Report PDF Action Plan
Oct 2025
London
An Independent Investigation into the care and treatment of Mr M
This is a learning bulletin from an independent review of Mr M’s care and treatment published on 15 October 2025.
12 recommendations Report PDF
Sep 2025
Midlands
An independent investigation into the care and treatment of SV
· 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 …
9 recommendations Report PDF
Sep 2025
Midlands
An Independent Investigation into the care and treatment of Mr B
This investigation relates to the care and treatment of Mr B during the period between October 2020 and 11 July 2023 when a homicide took place. At the time of the incident the service …
5 recommendations Report PDF
Aug 2025
North East and Yorkshire
An independent investigation into the care and treatment of Mr L: Published August 2025
This is the executive summary of the independent investigation into the care and treatment of Mr L.
7 recommendations Report PDF
Jul 2025
North East and Yorkshire
An Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud Nazir: Published July 2025
Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud Nazir Appendices The report has also been published on the following websites:
17 recommendations Report PDF
May 2025
North East and Yorkshire
An assessment of a mental health trust’s internal investigation of the care and treatment received by MB: Published May 2025
This is the summary report of an assessment of a mental health trust’s internal investigation of the care and treatment of MB.
7 recommendations Report PDF
Apr 2025
East of England
An independent investigation into the care and treatment of Colin – April 2025
This independent review commissioned by NHS England looks at the care and treatment that Colin received between January 2021 and his subsequent death in September 2021. The review included the nature and extent of …
17 recommendations Report PDF Action Plan
Apr 2025
North East and Yorkshire
An independent review into the care and treatment given to George: Published April 2025
This is the shared learning bulletin from an independent review into the care and treatment given George .
3 recommendations Report PDF
Apr 2025
South East
An independent investigation into the care and treatment of Christopher Stone-Houghton by Hampshire and Isle of Wight Healthcare NHS FT: April 2025
Hampshire and Isle of Wight Healthcare NHS FT
This is the report of the care and treatment of Mr Christopher Stone-Houghton APRIL 2025
6 recommendations Report PDF
Apr 2025
South East
Independent investigation into the care and treatment of Christopher Stone-Houghton by Hampshire and Isle of Wight Healthcare NHS FT: April 2025
Hampshire and Isle of Wight Healthcare NHS FT
This is the report of the care and treatment of Mr Christopher Stone-Houghton APRIL 2025
6 recommendations Report PDF
Mar 2025
North East and Yorkshire
An independent investigation into the care and treatment of Mr J: Published March 2025
This is the executive summary of the independent investigation into the care and treatment of Mr J.
4 recommendations Report PDF
Mar 2025
North East and Yorkshire
An assessment of a mental health trust’s internal investigation of the care and treatment of JP: Published March 2025
This is the summary report of an assessment of a mental health trust’s internal investigation of the care and treatment of JP.
10 recommendations Report PDF

By region

10 regions

London

172 investigations

North East and Yorkshire

141 investigations

South East

107 investigations

East of England

87 investigations

North West

86 investigations

South West

82 investigations

Midlands

75 investigations

Wales

17 investigations

Scotland

8 investigations

Northern Ireland

4 investigations