Findings are published today of an independent investigation into the circumstances surrounding the care and treatment of Mr O.

Sincerest sympathies are offered to all the people who have been affected by this tragic event. We speak of two victims in this incident; Ms M who was tragically killed, and Mr O, who was let down by the NHS and other organisations involved in his care and treatment.

Mr O was charged and convicted of the murder of Ms M. He had a long and complex mental health history and had previously had contact with mental health services in the South of England and was in contact with Hertfordshire Partnership University NHS Foundation Trust at the time of the incident.

Dr David Levy, Medical Director at NHS England – Midlands and East said: “We would like to offer our sincere sympathies to the people who have been affected by this tragic incident.

“Thankfully, events such as this are rare. However, when they do occur, we work closely with the relevant organisations to ensure that lessons are learned and any necessary improvements are put in place to ensure patient and public safety.”

The independent investigation was commissioned by NHS England following an internal investigation completed by Hertfordshire Partnership University NHS Foundation Trust into the events leading up to the death of Ms M. Alongside this, a Multi Agency Partnership Review into the death of Ms M was commissioned by Hertfordshire Adult Safeguarding Board.

The aim of this investigation is not to investigate the circumstances of the offence, but to enable the providers of care, and the whole of the NHS, to learn lessons and make improvements for the benefit of future patients, their carers and the public. We commission these reports so that the NHS is open and transparent with the families involved and the wider public about what took place and what the NHS is doing to fix it.

The investigation team’s view is that the incident could not have been predicted with any degree of certainty that would have made it possible to prevent.

In conducting their investigation, the team found that Hertfordshire Partnership University NHS Foundation Trust has taken steps to implement recommendations from their internal report, but also finds that additional recommendations need to be implemented to strengthen services further.

However, the investigation also found there were missed opportunities. One of the systemic missed opportunities in the treatment of Mr O was the lack of a single, coherent overall view of his history and care. This created a gap at the heart of care planning and risk assessment and negatively impacted inter-agency working. Lack of information about Mr O’s previous care was considered to have been one of the critical factors hindering appropriate risk assessment and management.

The report concludes that there are areas where additional learning can be unlocked for the NHS as a result of these tragic events and has made four recommendations:

1. Risk assessment and management
2. Communication
3. Mental health treatment requirement training
4. Discharge process

A copy of the full independent investigation report is available on our website.