Source · Investigations in the NHS

Independent investigation into NHS mental health care of ‘X’

East of England Published 01 Nov 2025

Index summary

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

Recommendations

4 total

1 Addressed to: The Trust Accepted

Link to recommendation 1

Recommendation · source text

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 awareness, and improve the quality of early assessments and treatments to reduce gaps that can exist in NHS primary, secondary and tertiary care between physical and mental health problems. The aim is to reduce delays to effective assessment, joined-up formulations, and reduce `diagnostic overshadowing4.’

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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 Addressed to: The Trust Accepted

Link to recommendation 2

Recommendation · source text

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 ensure that the delivery of, and effectiveness of, risk simulation training is audited to assess and monitor its effectiveness.

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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 Addressed to: The Trust Accepted

Link to recommendation 3

Recommendation · source text

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 carers, are considered within the context of their wider family relationships and their social networks (ref. `Think Family’ policy).

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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 Addressed to: The Trust Accepted

Link to recommendation 4

Recommendation · source text

`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, where appropriate, in partnership with primary care, be given brief psychological interventions, receive medication, be referred on and/or be monitored. In this way, key performance indicators of service-user satisfaction and access to specialised advice should be developed to assess and respond to this change.

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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

Acceptance status

Per recommendation

Accepted

Total recommendations

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.