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Mental Health Investigation

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

779 investigations 606 with recommendations indexed 6,452 recommendations indexed 117 action plans

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Investigations

779 matching investigations
Independent investigation: Chris Poole, Eastbourne (2012)
South East
Mentally ill man fatally punches and kicks man
6 recommendations Report PDF
Independent investigation: Chris Stones, Worthing (2005)
South East
Paranoid Schizophrenic stabs father of two. Long MH history
-1 recommendations Report PDF
Independent investigation: Christoph Duclos, Mile End Tube (2002)
London
Psychotic pushed stranger into oncoming train. Ind Inq 2006. Personality disorder and dual diagnosis
5 recommendations Report PDF
Independent investigation: Christopher Edwards, Chelmsford prison (1994)
East of England
Schizophrenic homicide. Ind Inq 1998, Coonan (European Court HR case)
-1 recommendations Report PDF
Independent investigation: Christopher Ritchie, Durham (2020)
North East and Yorkshire
Paranoid schizophrenic fatally stabbed acquaintance. Diminished responsibility – indefinite hospital order
6 recommendations Report PDF
Independent investigation: Claire Wilson (& unborn baby), Grimsby (2009)
North East and Yorkshire
Mentally ill man fatally stabs pregnant stranger killing her and her unborn daughter. Prev. 3 inpatient stays after threatening to kill someone with knives
17 recommendations Report PDF
Independent investigation: Clara Joughlin, Isle of Man (1995)
Northern Ireland
MH patient attacks two daughters, killing younger one. Ind Inq 1997. Long MH history
-1 recommendations Report PDF
Independent investigation: Colin Anderson, Newcastle (2006)
North East and Yorkshire
Recently released mentally ill man (with depressive LD accomplice) batters man and throws him off tower block.. Recently released after psychotic episode. Ind Inq due.
20 recommendations Report PDF
Independent investigation: Colin Beynon, Bristol (1995)
South West
Schizophrenic batters father to death with hammer on home visit. Ind Inq 1997 found “string of errors”
-1 recommendations Report PDF
Independent investigation: Colin Johnson, Sunderland (2004)
North East and Yorkshire
Paranoid schizophrenic kills former school friend with an axe.. long history of increasing MH problems. Family asked MH for help 83 times before incident.
-1 recommendations Report PDF
Independent investigation: Colin Ricketts, Laindon, Essex (2009)
East of England
Mentally ill man with paranoid delusions fatally stabs mother’s boyfriend
5 recommendations Report PDF
Independent investigation: Daniel Coleman, Norfolk (1996)
East of England
MH Homicide. Ind Inq 2001 Armstrong
-1 recommendations Report PDF
Independent investigation: Daniel Quelch, Maidenhead, Berks (2007)
South East
Paranoid Schizophrenic breaks into house and fatally and repeatedly stab stranger in front of his children. Long MH history – sectioned 2001 – not taking meds
9 recommendations Report PDF
Independent investigation: Darren Flynn, HMP Swaleside (2015)
London
Two mentally disordered prisoners repeatedly & fatally stabs fellow prisoner
2 recommendations Report PDF
Independent investigation: David Burrows, Ravensthorpe, Yorks (2005)
North East and Yorkshire
MH Homicide w knife whilst out on bail after conviction for assault. Ind Inq, (2005/3404) 2007. Previous hist of violence. Suicide in jail
6 recommendations Report PDF
Independent investigation: David Donnelly, Woolwich (2003)
London
Mentally ill man fatally stabs mentally ill neighbour. Long MH history, previous sec 37/41 but discharged & not recalled when unwell
-1 recommendations Report PDF
Independent investigation: David Fairburn, Barking (2004)
London
Homicide by mentally ill. Ind Inq 2010 NHS
4 recommendations Report PDF
Independent investigation: David Huitson, Newcastle (2001)
North East and Yorkshire
Schizophrenic stabbed victim who had given evidence against him in another stabbing case.. Ind Inq 2004 – history of previous violence.
-1 recommendations Report PDF
Independent investigation: David Kemp, Great Yarmouth (2008)
London
MH patient absconds from secure unit and murders stranger. Previous serious violence
17 recommendations Report PDF
Independent investigation: David Limb, Wath (2004)
North East and Yorkshire
MH Homicide (+ alcohol). Ind Inq (2004/680) 2008
5 recommendations Report PDF
Independent investigation: David Philips, London (1998)
London
MH homicide. Ind Inq 2000
-1 recommendations Report PDF
Independent investigation: David Turnbull, Co Durham (1997)
North East and Yorkshire
MH homicide. Ind Inq 2000
-1 recommendations Report PDF
Independent investigation: Dean Shorney, Bargoed (2006)
Wales
MH patient fatally and repeatedly stabs victim.. Critical Ind Inq 2008. Known high risk of violence.
5 recommendations Report PDF
Independent investigation: Debra Larn, Leicester (2006)
Midlands
MH patient fatally stabbed neighbour and wounded another (PD). Ind Inq 2007. Long MH history with violence. Predictable & preventable. Warnings. Poor team working.
-1 recommendations Report PDF
Independent investigation: Denis Finnegan, Richmond Park (2004)
London
Psychotic fatally stabbed stranger whilst released from secure unit by Psych.. Ind Inq 2006. Errors made. Previous history of stabbing strangers
1 recommendation Report PDF

By region

11 regions

London

162 investigations

North East and Yorkshire

137 investigations

South East

99 investigations

Midlands

80 investigations

East of England

78 investigations

South West

78 investigations

North West

75 investigations

Wales

27 investigations

Scotland

25 investigations

National

13 investigations

Northern Ireland

5 investigations