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Independent investigation into NHS mental health care of ‘X’

East of England Published 01 Nov 2025

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, Y, was subsequently found to have died due to strangulation. The Major Crime Team concluded that the deaths were due to murder and suicide. Documents Independent Assurance Review – Assurance of the investigation report and action plan relating to the care and treatment received by PS prior to homicide

Report PDF Action Plan NHS England Source
Jump to 4 recommendations

Acceptance status

Per recommendation
Accepted
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 The Trust Accepted
Recommendation
The Trust should continue to develop and reinforce links between mental and physical care not only in relation to care provision, but also communications within the primary, mental health and acute hospital sectors. The aim is to train staff, raise … Read more
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Divisional Pilot GP physical July 2026 in line Ongoing management health projects to with delivery of team strengthen the reshaped CMH interface with Service primary care are underway Nursing Complete Q1 Fundamentals of 25/26 Care supports in- clinic tracking of physical health and ensuring that GPs are alerted to any physical health concerns and treatment plans The Hertfordshire In place and and West Essex ongoing `Shared Care Record brings together information from the electronic records held by different organisations. This allows health and care professionals to access a real- time summary of key information, safely and securely to support care delivery. HPFT is Commenced collaborating with Q2 2025 health and other partners on developing neighbourhood health partnerships and integrated MDTs There is a continued focus across adult community mental health services on strengthening of physical health monitoring and communication across primary and secondary care for those with identified comorbidities. Ongoing
2 The Trust Accepted
Recommendation
The Trust has taken a range of significant steps to improve the way that training about risk is undertaken (including risk of suicide in association with physical problems such as chronic pain or physical disability). However, the Trust should now … Read more
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Trust’s Research Deputy Medical Questionnaires September 2023 In place Team and Director completed pre Simulation and post training Faculty members which informs to evaluate the developing and impact of the delivery of the Trust’s suicide training prevention Evaluation Q1 2026 simulation-based methodology has Ongoing training been developed and co-produced with people with lived experience for roll out Ongoing In place
3 The Trust Accepted
Recommendation
The Trust should review and increase awareness amongst staff of the need for holistic assessments of service users; this means ensuring that the Trust strengthens and maintains DIALOG, the new care planning framework to ensure that assessments, including assessments for … Read more
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Trust to consider Divisional The Primary Ongoing ways in which to Director Mental Health further embed Services the use of Dialog Operational assessments to Policy sets out assess solution-focused individualized approach using needs and the Dialog+ tool support care as a framework delivery. and baseline measure with a goal focused plan agreed with the service user. Ongoing Ongoing
4 The Trust Accepted
Recommendation
`The `Community Transformation’ model should be evaluated to ensure that it is possible to refer patients on, obtain a specialised opinion, and take a more team-based focus. The aim is to ensure that service users can be assessed as outpatients, … Read more
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Trust to maintain Divisional Community Early 2024 Ongoing oversight of the Director & transformation community Clinical Director project informed transformation by learning from project and this incident. related workstreams through existing Progress and Ongoing governance delivery committees. monitored through Transformation and Improvement Board with oversight by Executive Team and HWE ICB Ongoing Ongoing