Apr 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 …
Mental Health Investigation
17 recommendations
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Action plan
Jan 2025
Cambridge University Hospitals NHS Foundation Trust
Mental Health Investigation
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Oct 2024
Central and North-West London NHS Foundation Trust
A pathway review was commissioned by NHS England to understand the service changes made after a serious incident involving a death several years ago. The perpetrator was a young man who had …
Pathway Review
4 recommendations
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Aug 2024
Norfolk and Suffolk Mental Health NHS Foundation Trust
This independent review report has been commissioned by NHS England relating to the care provided by Norfolk and Suffolk Mental Health NHS Foundation Trust for an individual who was responsible for the …
Mental Health Investigation
4 recommendations
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Apr 2024
Quality Assurance Review
5 recommendations
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Jun 2023
Norfolk and Suffolk NHS Foundation Trust
This report was commissioned by the trust and made twelve recommendations to improve the care and treatment of service users, and three recommendations to improve practice following a serious incident. The investigation …
Pathway Review
9 recommendations
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Dec 2022
Quality Assurance Review
14 recommendations
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Aug 2022
Norfolk and Suffolk NHS Foundation Trust
The independent assurance review provides an assessment of the implementation of the actions developed in response to recommendations from the independent investigation into the care and treatment of Mr K in Suffolk.
Quality Assurance Review
6 recommendations
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Jan 2022
Cambridgeshire and Peterborough NHS Foundation Trust
The findings of an independent investigation into the circumstances surrounding the care and treatment of Mr D are published on this webpage. Mr D had a diagnosis of paranoid schizophrenia and recurrent …
Mental Health Investigation
6 recommendations
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Action plan
Dec 2021
Mental Health Investigation
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Aug 2021
This investigation was commissioned by NHS England and was conducted in partnership with the Domestic Homicide Review which was commissioned by Southend, Essex and Thurrock Domestic Abuse Board. The investigation was prompted …
Mental Health Investigation
12 recommendations
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Action plan
Jul 2021
The findings of an independent investigation into the circumstances surrounding the care and treatment of Mr Z are published on this webpage: Essex Partnership University Trust and NHS Thurrock ICS, which are …
Mental Health Investigation
5 recommendations
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Action plan
Dec 2020
The findings of an independent investigation into the circumstances surrounding the care and treatment of Mother in Essex are published on this webpage. Mother had been under the care of secondary mental …
Mental Health Investigation
3 recommendations
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Action plan
Nov 2020
The findings of an independent investigation into the circumstances surrounding the care and treatment of James are published on this webpage. James killed his long-term girlfriend in December 2017. He had been …
Mental Health Investigation
7 recommendations
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Action plan
Nov 2020
Mental Health Investigation
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Nov 2020
Bedfordshire Hospitals NHS Foundation Trust
Maternity and Neonatal
9 recommendations
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Sep 2020
Norfolk and Norwich University Hospitals
Mental Health Investigation
7 recommendations
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Jun 2020
Findings are published today of an independent investigation into the circumstances surrounding the care and treatment of Mr P, a mental health service user in Essex . Sincerest sympathies are offered to …
Mental Health Investigation
5 recommendations
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Action plan
Oct 2019
To ensure that NHS England continues to commission high quality independent investigations that influence and support system wide development and improvement, NHS England commissioned an external review of all Independent Investigations following …
Mental Health Homicide Review
9 recommendations
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Sep 2019
This independent investigation arises from the murder of Russell, 37, on 13 June 2013. Mr K admitted manslaughter on the grounds of diminished responsibility and was detained indefinitely under the Mental Health …
Mental Health Investigation
6 recommendations
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Sep 2019
Sally. He had a long and complex mental health history and had previously had contact with mental health services at Northamptonshire Healthcare NHS Foundation Trust
The findings of an independent investigation into the circumstances surrounding the care and treatment of Tom are published on this webpage. Tom was charged and convicted of the manslaughter by diminished responsibility …
Mental Health Investigation
7 recommendations
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Jan 2018
Hertfordshire Partnership University NHS Foundation Trust
Patient Mr O killed Ms M and was convicted of her murder. He was in contact with mental health services delivered by Hertfordshire Partnership University NHS Foundation Trust and was previously a …
Mental Health Investigation
4 recommendations
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Mar 2017
Patient M killed his cellmate in HMP Peterborough and was subsequently convicted of manslaughter on the grounds of diminished responsibility. The investigation was conducted jointly with the Prison and Probation Ombudsman (PPO) …
Mental Health Investigation
11 recommendations
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Nov 2016
Independent review to follow up care provided for Mr Q at Hertfordshire Partnership University NHS Foundation Trust
Mental Health Investigation
5 recommendations
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Dec 2015
South Essex Partnership University NHS Foundation Trust
Patient Y was convicted of the murder of Mr Z in June 2011. The patient used services provided by South Essex Partnership University NHS Foundation Trust. Services have now transferred to East …
Mental Health Investigation
9 recommendations
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Action plan