Independent investigation reports

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).

The associated action plan has been published by the 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