Feb 2026
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 …
Mental Health Investigation
6 recommendations
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Jan 2026
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 …
Mental Health Investigation
4 recommendations
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Sep 2025
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 …
Mental Health Investigation
9 recommendations
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Sep 2025
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 …
Mental Health Investigation
5 recommendations
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Aug 2025
Black Country Healthcare NHS Foundation Trust
A Pathway Review of care for people with severe mental ill health who present a level of risk to others in Black Country Healthcare NHS Foundation was designed to support learning and …
Pathway Review
2 recommendations
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Feb 2025
The investigation was commissioned by NHS England following the fatal stabbings of three people in Nottingham in June 2023. Three others sustained serious injuries. The purpose of the investigation is to help …
Mental Health Investigation
12 recommendations
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Action plan
Nov 2024
Shrewsbury and Telford NHS Trust
Maternity and Neonatal
3 recommendations
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Mar 2024
The investigation resulted from the death of a woman and her male child in 2021 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of …
Mental Health Investigation
3 recommendations
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Action plan
Nov 2023
Mental Health Investigation
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Sep 2023
The investigation resulted from the death of a 87 year-old man in 2019 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the investigation …
Mental Health Investigation
5 recommendations
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Action plan
Sep 2023
University Hospitals Birmingham NHS Foundation Trust
Mental Health Investigation
16 recommendations
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Jul 2023
The investigation was prompted by an incident in Birmingham in 2020 that resulted in: The purpose of the investigation was to help the NHS and partners understand if there are lessons that …
Mental Health Investigation
5 recommendations
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Action plan
Jun 2023
University Hospitals Birmingham NHS Foundation Trust
Mental Health Investigation
20 recommendations
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Apr 2023
The investigation resulted from the death of a 59 year-old woman in 2018 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the investigation …
Mental Health Investigation
6 recommendations
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Action plan
Nov 2022
Quality Assurance Review
14 recommendations
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Nov 2022
Mental Health Investigation
57 recommendations
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Aug 2022
Leicestershire Partnership NHS Trust
The investigation was prompted by the death of a 92 year-old man in 2019 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the …
Mental Health Investigation
3 recommendations
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Action plan
Mar 2022
The Shrewsbury and Telford Hospital NHS Trust
Donna Ockenden
Independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, commissioned by the Secretary of State for Health and Social Care in 2017. Led by Donna Ockenden (senior midwife). …
Maternity and Neonatal
15 recommendations
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Mar 2022
University Hospitals of North Midlands NHS Trust
Mental Health Investigation
7 recommendations
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Feb 2022
The investigation was prompted by the death of a 34 year-old man in 2017 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the …
Mental Health Investigation
3 recommendations
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Action plan
Dec 2021
Quality Assurance Review
10 recommendations
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Aug 2021
The investigation was prompted by the death of a 37 year-old woman in 2017 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the …
Mental Health Investigation
11 recommendations
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Action plan
Nov 2020
This investigation was prompted by the death of a nine-year-old boy in 2014 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the investigation …
Mental Health Investigation
16 recommendations
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Action plan
Jul 2020
Shrewsbury and Telford NHS Trust
Maternity and Neonatal
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Jan 2020
Mr N was released from prison whilst detainable, but no suitable bed could be found. Mr N approached a policeman saying he was hearing voices telling him to kill people. The policeman …
Mental Health Investigation
10 recommendations
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