Publication of independent investigation report into the care and treatment of Mr P in Essex

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 all the people who have been affected by this tragic event. Mr P killed Mrs H and Mr F at his mother’s address in Essex on 22 July 2015. Mr P was convicted of the murder of the two victims, who were his mother and her friend, and received a life sentence in May 2016.

Mr P had had contact with mental services at various points with North Essex Partnership University NHS Foundation Trust and then Essex Partnership University NHS Foundation Trust since a first referral in 2010, up to and after the incident.

Catherine Morgan, director of nursing for NHS England and NHS Improvement in the East of England, 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.”

NHS England and NHS Improvement (East of England) commissioned this independent investigation which follows the NHS England Serious Incident Framework (March 2015) and Department of Health guidance on Article 2 of the European Convention on Human Rights and the investigation of serious incidents in mental health services.

The requirement was for an independent investigation to support the Domestic Homicide Review which was commissioned by Uttlesford Community Safety Partnership.

The main purpose of an independent investigation is to ensure that mental health care related homicides are investigated in such a way that lessons can be learned effectively to prevent recurrence. The investigation process may also identify areas where improvements to services might be required which could help prevent similar incidents occurring.

The aim of this independent 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 careers 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.

In the case of Mr P, and in relation specifically to the predictability of the homicides carried out by him, it is concluded that his actions were not predictable by mental health services at the time of the offences.

He had been released from prison in the context of being mentally well, not using illicit substances and not expressing any paranoid thinking. He had not required the input of prison mental health in-reach services for almost a year before his release; and his only contact with services following release was to facilitate access to benefits.

Following the offence he was deemed mentally well and thought not to be suffering any mental disorder.

None of the specific mental health issues which could suggest an increased likelihood of violent behaviour from Mr P were present at the time of the offences. He had been seen by his GP after release in April 2015, who made an urgent referral for an assessment by mental health services, but did not raise any concerns about his mental state.

The report authors concluded that it would not have been possible for mental health services to predict or prevent Mr P’s actions on the day of the homicides.

However, it did find a number of areas where best practice and policy were not adhered to. The Trust (North Essex Partnership University NHS Foundation Trust) no longer exists in its previous form, and service provision has been redesigned.

Where the report authors had evidence of improvement, it did not make recommendations; in the areas of domestic violence and risk assessment training, management of waiting times in the psychosis service, and the oversight of quality of individual management reports (IMRs).

The report made four recommendations for the new Trust (Essex Partnership University NHS Foundation Trust) and one for NHS England and NHS Improvement as the commissioners of prison healthcare:

Recommendation 1
The Trust should provide evidence that their revised domestic abuse and safeguarding training is being delivered, by reporting on and monitoring training and safeguarding supervision figures against targets.

Recommendation 2
The Trust should ensure that appropriate communication links are maintained and monitored with Multi Agency Risk Assessment Teams (MARAT)

Recommendation 3
The Trust should implement structures to monitor adherence to policy guidance with regard to transfers of care, transition from services and inclusion of the service user and carers in the process.

Recommendation 4
Trust CPA and discharge policies should provide clear guidance on how liaison with prison services mental health teams will occur at entry and exit, to maintain continuity of care.

Recommendation 5
Commissioners of prison health services in the East, North Midlands and the South must ensure that robust procedures are in place to maintain continuity of mental healthcare in prison, on reception and on inter-prison transfer when a prisoner has received secondary mental health care in the community.

View a copy of the full independent investigation report.



  • NHS England and NHS Improvement has addressed Recommendation 5 with the publication in 2018 of a new service specification for mental health services in prisons. Objective 3 relates to improved continuity of care through the gate and within the prison system and includes requirements for prison healthcare teams to:
    • develop strong links and clear referral pathways to ensure continuity of care for service users being transferred between custodial settings to community and vice versa.
    • develop robust plans and mechanisms for continuity of care for clients on their release from custody to whichever region or local authority they are returning to. The plans should form part of an overarching recovery, treatment and/or care plan, which is discussed with the service user and community providers at the earliest opportunity.
  • Implementation of this service specification included additional funding to increase the availability of prison based mental health services.