Independent investigation reports

An independent inquiry into the care and treatment of Mr S

This relates to the investigation commissioned by NHS England (South) into the care and treatment of Mr S who was receiving his care and treatment from Somerset Partnership NHS Foundation Trust. He stabbed his landlord in Bridgwater in April 2011. Mr S was arrested for murder and the judge ordered him to be detained without time limit at a secure mental health hospital. Mr S has since died. NHS England and NHS Somerset Clinical Commissioning Group held a meeting on 29 September 2014 which was attended by the family and the Trust to discuss the findings and next steps. There will be an independent review of the action plan in the next six months. The independent investigation report is published here.

An independent inquiry into the care and treatment of Y and X

This is a legacy investigation which goes back to 2003 commissioned by the former South East Coast Strategic Health Authority. In April 2003, Y killed X and pleaded not guilty for her murder. X and Y were informal patients at the former Medway Maritime Hospital in Kent. X was sentenced to a minimum term of 19 years in 2004. Due to a number of service reorganisations, names of Trusts have changed and staff have moved roles. The final report is published here.

An independent inquiry into the care and treatment of Ms B

This was a joint independent investigation conducted by the former South Central Strategic Health Authority in partnership with the Oxford Safer Communities Partnership. The investigation relates to the care and treatment of Adult B who was a patient at Oxford Health NHS Foundation Trust July 2013. Adult B stabbed her mother and was found guilty of manslaughter on the grounds of diminished responsibility. The judge imposed a Hospital Order under the Mental Health Act (1983). Adult B has since passed away. The final report is published here.

An independent inquiry into the care and treatment of Mr Z

Mr Z had a forensic history and was feeling anxious and depressed. Attempts were being made for him to access services from the Sussex Partnership NHS Foundation Trust. In September 2010 Mr Z was arrested for the murder of Mr X and in March 2011 he was jailed for life, with a further seven years added for attempting to pervert the course of justice. The final report and executive summary are published here.

An independent inquiry into the care and treatment of Mr B

NHS England are publishing an independent review of an action plan following a report previously published by the former NHS South of England Strategic Health Authority. The initial report published in February 2013 identified a number of service issues and this independent review published here provides an update on the actions taken by the Sussex Partnership NHS Foundation Trust since that time. The review, conducted independently by the initial independent investigators will give some assurance to families, commissioners and the wider public that follow ups will be conducted after an investigation.

Independent investigation into the care and treatment of Mr T and Mr U

NHS England (South) commissioned an independent investigation into the care and treatment of Mr T and Mr U was an ex-mental health service-user from Berkshire Healthcare NHS Foundation Trust. Mr T stabbed and killed Mr U, a mental health service-user in March 2012. Mr T was convicted of murder and jailed for life on in November 2012.

NHS England, the family, West Berkshire Clinical Commissioning Group federation and Berkshire Healthcare NHS Foundation Trust held a meeting on 21 October 2014 to hear the independent investigation’s findings. The investigation did not find that the incident could have been predicted or prevented but it highlighted other service issues that need improvement. The Trust accepted the report and its recommendations and will work with NHS England to conduct an independent review of the action plan.

The report and action plan are published here.

Independent investigation into the care and treatment of Mr P

NHS England’s South region has published a mental health homicide legacy report. This was commissioned by the former Strategic Health Authority, but not published before that organisation was abolished on 31 March 2013.

The report relates to Mr P who was convicted of murder in January 2010. Mr P and his victim both received mental health services from Kent and Medway NHS Social Care and Partnership Trust.

Independent investigation into the care and treatment of Mr DE

This is the independent investigation into the care and treatment of Mr DE  who was in receipt of psychiatric services provided by South London and Maudsley NHS Foundation Trust.  Mr DE murdered Miss FG on 19th November 2011 at the home of his uncle. Mr DE was known to the mental health service for ten months prior to the homicide and at the time of the offence he was receiving care and treatment from the Lewisham Early Intervention Services.

The associated action plan has been published by the Trust.

NHS England’s South region has published four mental health homicide investigation legacy reports. These are reports which were commissioned and considered by the former strategic health authorities which operated in the south region, but were not published before those organisations were abolished on 31st March 2013.

The reports relate to:

  • Mr B, who received his care and treatment at Kent and Medway Social Care and NHS Partnership Trust. He had a history of paranoid thoughts and persecutory thoughts. In April 2007 he killed his wife and later committed suicide.
  • Mr Y, a former patient at Sussex Partnership NHS Foundation Trust and The Priory. Mr Y killed his wife and then committed suicide. He had previous attempts of committing suicide and threats to kill his wife. HM Coroner recorded a verdict of “unlawful killing” with respect to Mrs Y’s death and a narrative verdict with respect to Mr Y’s death. See also the Exectuive Summary.
  • Mrs G, a former patient at the Surrey and Borders NHS Foundation Trust stabbed her husband in September 2010. Mrs G briefly received short term care and support from the Trust during times of need. She was convicted of manslaughter and sentenced to 582 days in prison but was released having served 291 days on remand.
  • Mr X, a former patient from Sussex Partnership NHS Foundation Trust. He had a long history of violent crimes which started early in his childhood and included drugs and alcohol abuse and Attention Deficit Hyperactivity Disorder. He killed Mr A in April 2011 and was convicted for murder and sentenced to 36 years in prison with a minimum of 18 years. He remains in prison. See also the Executive Summary.

Independent investigation into the care and treatment of Mr C and Mr D

This is the independent investigation into the care and treatment of Mr C and Mr D who were both in receipt of psychiatric services provided by Camden and Islington NHS Foundation Trust.  Mr C was also known to the Barnet, Enfield and Haringey NHS Trust, having been an inpatient of the North London Forensic Service.  They were both residents at the Camden Resettlement Project where Mr C, attacked and killed Mr D on 12 May 2011.

The associated action plan has been published by both trusts.

Independent investigation into the care and treatment of Mr MC and the homicide of Mr GN

This is the independent investigation into the care and treatment of Mr MC. Mr MC has a long history of contact with mental health services, and has been admitted to high and medium secure hospitals in the past. He has also spent time in prison for serious assaults. He has been consistently diagnosed with paranoid schizophrenia and some personality difficulties/dissocial personality disorder.

On 17 March 2012 Mr MC fatally stabbed Mr GN with a samurai sword in the Keystones shared house in Bristol. Mr MC was on trial leave at the Keystones house, under section 17 of the Mental Health Act (1983).

At Bristol Crown Court, Mr MC was given an indeterminate sentence for the protection of the public and is detained in hospital for treatment. He remains at Broadmoor and will not be considered for release without it being sanctioned by the Secretary of State or a tribunal.

Mr MC was a patient at Fromeside Medium Secure Unit in Bristol, a service which was commissioned by the former South West Strategic Health Authority. At the time of the incident he had been in Fromeside for twelve months and appeared to be making good progress, was relatively symptom free, was becoming engaged with community activities, complying with medication, and had been free from alcohol and illicit drugs. There had been no actual physical assaults for twelve months.

South West Strategic Health Authority commissioned the care of Mr MC but NHS England took over the responsibility for commissioning these services as specialist commissioners following the reconfiguration of the NHS in 2013.

The Trust response to the Niche Independent Inquiry into the care and treatment of a mental health service user (MC) in Bristol is available here.

Independent investigation into the care and treatment of Patient E

This is the Executive Summary of the Independent Investigation into the care and treatment of Patient E, who was convicted of the manslaughter of Victim E. In 2008, Patient E assaulted Victim E, inflicting serious head injuries which resulted in victim E’s death in hospital. At the time of the death Patient E was receiving mental health services provided by Northumberland, Tyne and Wear NHS Foundation Trust.

The full independent investigation report has been considered and received by Northumberland, Tyne and Wear NHS Foundation Trust and by South Tyneside Clinical Commissioning Group. The associated action plan arising from the investigation is also published here and on the websites of the trust and the CCG.

Independent investigation into the care and treatment of Mr A

This is the independent investigation into the care and treatment of Mr A. Mr A, of Hemel Hempstead, had been in receipt of mental health services because he was living with a personality disorder from 1997 until he committed his crime in 2007. Mr A was found guilty of murder in April 2008 and is currently serving a 16 year jail sentence.

Mr A regularly misused drugs and alcohol and in the view of the psychiatrists who assessed him he was a risk to himself and others.

Mr A was treated by Dacorum Community Mental Health Team, a service which is commissioned by Hertfordshire Partnership University NHS Foundation Trust.

The associated action plan has been published by Hertfordshire Partnership University NHS Foundation Trust.

Independent investigation into the care and treatment of Mr R

This is the independent investigation into the care and treatment of Mr R. Mr R had spent nine years in prison before being admitted to Rampton Hospital (Forensic High Secure Hospital).  He had actively sought admission to attempt to address his personality difficulties.  He progressed from Rampton to a medium secure unit Arnold Lodge both under Nottinghamshire Healthcare NHS Trust and was then discharged into the community in Northamptonshire under the care of Northamptonshire Healthcare NHS Foundation Trust.  After spending a year in the community, in September 2008 he attacked a 67-year-old man, who subsequently died from his injuries.  He is now serving a sentence for his actions in prison.

The associated action plan has been published by Northamptonshire Healthcare NHS Foundation Trust.

The associated action plan has been published by Nottinghamshire Healthcare NHS Trust.

The associated action plan has been published for NHS England, Leicestershire and Lincolnshire Area Team Specialised Commissioning Services.


NHS England’s South region has published four mental health homicide investigation legacy reports. These are reports which were commissioned and considered by the former strategic health authorities which operated in the south region, but were not published before those organisations were abolished on 31st March 2013.

The reports relate to:

Independent investigation into the care and treatment of Mr A

This is the independent investigation into the care and treatment of Mr A. Who, under the care of Older People’s Community Mental Health Team (OPCMHT) in the East Adult Mental Health Clinical Service Line, attacked his wife on 25 June 2010, resulting in her being admitted to hospital where she died of her injuries on 28 June 2010. At the time of the death Mr A was receiving mental health services provided by Cheshire and Wirral Partnership Trust.

The associated action plan has been published by the Trust.

Independent investigation into the care and treatment of Mr F

This is the independent investigation into the care and treatment of Mr F. Who, under the care of Blackburn and Darwen complex care team, attacked and killed a 22-year-old man on 16 April 2011. At the time of the death Mr F was receiving mental health services provided by Lancashire Care NHS Foundation Trust.

The associated action plan has been published by the trust.

Independent investigation into the care and treatment of Miss E

This is the independent investigation into the care and treatment of Miss E, who stabbed and killed her mother on 23 March 2011. At the time of the death Miss E was receiving mental health services provided by Lancashire Care NHS Foundation Trust.

The associated action plan has been published by the trust.

Independent investigation into the care and treatment of Mr W

The independent investigation into the care and treatment of Mr. W was commissioned by NHS North West Strategic Health Authority pursuant to HSG (94)27.1 This Investigation was asked to examine a set of circumstances associated with the death of Ms. Y.

Independent investigation into the care and treatment of Patient I

This is the independent investigation into the care and treatment of Patient I, who killed Victim I by stabbing him with a knife on 2 July 2010. At the time of the death Patient I was receiving mental health services provided by Northumberland, Tyne and Wear NHS Foundation Trust.

The associated action plan has been published by the trust.

Independent investigation into the care and treatment of Patient 2009/3245

This is the independent investigation into the care and treatment of Patient 2009/3245, who attacked and killed his girlfriend Victim A on 3 or 4 April 2009. At the time of the death Patient 2009/3245 was receiving mental health services provided by Tees, Esk and Wear Valleys NHS Foundation Trust.

The associated action plan has been published by the trust.

Independent investigation into the care and treatment of Patient G

This is the independent investigation into the care and treatment of Patient G, who killed Victim G on 3 January 2009. At the time of the death Patient G was receiving mental health services provided by Northumberland, Tyne and Wear NHS Foundation Trust.

The associated action plan has been published by the trust.

Independent investigation into the care and treatment of Patient C

This is the independent investigation into the care and treatment of Patient C, who stabbed and killed Victim C on 15 July 2007. At the time of the death Patient C was receiving mental health services provided by Northumberland, Tyne and Wear NHS Foundation Trust.

The associated action plan has been published by the trust.

Independent investigation into the care and treatment of Mr A

This is the report of the Independent Investigation into the Care and Treatment of Mr A, a 46-year-old man who stabbed his neighbour in her home on 30 April 2010, after he had been in brief contact with the services of West Hertfordshire Hospitals NHS Trust, and Hertfordshire Partnership NHS Foundation Trust.

The associated action plan for NHS England.

Mental health homicide investigation legacy reports

NHS England’s South region has published three mental health homicide investigation legacy reports. These are reports which were commissioned and considered by the former NHS South of England Strategic Health Authority, but were not published before that organisation was abolished on 31st March 2013.

The reports relate to:

Independent investigation into the care and treatment of Mr Z

This is the Independent Investigation into the Care and Treatment of Mr Z, a 41-year-old man who murdered his ex-partner at his home in November 2010, while he was under the care of the Manchester Mental Health and Social Care NHS Trust.

The purpose of an Independent Investigation is to review thoroughly the care and treatment received by the patient in order to establish the lessons to be learnt, to minimise the possibility of a reoccurrence of similar events, and to make recommendations for the delivery of Health Services in the future, incorporating what can be learnt from a robust analysis of the individual case.

The Trust will display their action plan for dealing with recommendations on their web site.

Independent investigation into the care and treatment of Mr X

This is the Independent Investigation into the Care and Treatment of Mr X, a 59-year-old man who murdered his estranged wife at his home on 23 December 2009, while he was under the care of the Hertfordshire Partnership Foundation Trust.

Independent investigation into the care and treatment of Mr J

This is the Independent Investigation into the Care and Treatment of Mr J, who stabbed and killed his mother at home on 15 March 2010, while he was under the care of the former Suffolk Mental Health Partnership NHS Trust (now the Norfolk and Suffolk NHS Foundation Trust).

Independent investigation into the care and treatment of Mr H

This is the Independent Investigation into the Care and Treatment of Mr H, who assaulted his mother on 26 June 2010, while he was visiting the home of his brother. His mother later died from her injuries. At the time of the assault Mr H was under the care of the South Essex Partnership University NHS Foundation Trust.

The associated action plan has been published by the Trust.

Publication of an independent investigation into the care and treatment of Mr G – 23 August 2013

Findings were published today of an independent investigation into the healthcare and treatment of a man who stabbed his wife to death at their family home on 5 March 2011.

Mr G had been assessed by staff from Kent and Medway NHS and Social Care Partnership Trust in the months before the incident. He had also consulted his GP.

On 21 November 2011 Mr G was found guilty of manslaughter and he is currently in jail.

NHS South of England commissioned an independent investigation to evaluate the mental health care and treatment of Mr G and the investigation report is now available.

Independant investigation into the care of Mr A by the Mental Health In-Reach Team (MHIRT) at HMP Peterborough – 22 August 2013

The independent investigation report of a mental health service user manslaughter case at HMP Peterborough.

The investigation reports on the care and treatment provided in the case that occurred on September 11, 2008, while the service user was under the care of the Cambridge & Peterborough NHS Foundation Trust.

East of England Strategic Health Authority commissioned the independent investigation report into the care and treatment of the patient, to ensure the case was reviewed independently, as stipulated under the requirements of Department of Health Guidance HSG (94)27 (amended 2005).

Here NHS England publishes the report of the independent investigation carried out for this case.

The report made a total of 11 [eleven] recommendations for which the Trust has produced an action plan to ensure the recommendations are implemented. This can be viewed here: Cambridge & Peterborough NHS Foundation Trust action plan