Independent investigation reports for East of England

Details are given of the independent investigation reports that have been published by NHS England from April 2013. Where a report is marked with an asterisk* the investigation was started before NHS England was established, but the final report was published after 1 April 2013:

An independent review of the Independent Investigations for Mental Health Homicides in England (published and unpublished) from 2013 to 2017

To ensure that NHS England continues to commission high quality independent investigations that influence and support system wide development and improvement, NHS England commissioned an external review of all Independent Investigations following Mental Health Homicides (IIMHH) and the national governance arrangements underpinning this work. The review considered investigations undertaken between 2013 – 2017.

NHS England have accepted the report findings and have developed an action plan which is being implemented and monitored via the regional and national governance mechanisms.

NHS England’s Independent Investigation Governance Committee would like to thank the authors, external partners, lay representatives and regional leads who contributed to the review.

An independent investigation into the care and treatment of a mental health service user Mr. K in Suffolk

This independent investigation arises from the murder of Russell, 37, on 13 June 2013. Mr K admitted manslaughter on the grounds of diminished responsibility and was detained indefinitely under the Mental Health Act.

An independent investigation into the care and treatment of a mental health service user (Tom) in Cambridgeshire

The findings of an independent investigation into the circumstances surrounding the care and treatment of Tom are published on this webpage.

Tom was charged and convicted of the manslaughter by diminished responsibility of his wife Sally. He had a long and complex mental health history and had previously had contact with mental health services at Northamptonshire Healthcare NHS Foundation Trust and was in contact with Cambridgeshire and Peterborough NHS Foundation Trust at the time of the incident.

The independent investigation was commissioned by NHS England following internal investigations completed by Northamptonshire Healthcare NHS Foundation Trust and Cambridgeshire and Peterborough NHS Foundation Trust into the events leading up to the death of Sally. This investigation was conducted in partnership with the Domestic Homicide Review into the death of Sally, which was commissioned by Huntingdonshire Community Safety Partnership.

The organisations cited in the independent investigation report and the Domestic Homicide Review have published action plans in response to the findings:

Independent Review into the NHS Care and Treatment Provided to Mr O

Patient Mr O killed Ms M and was convicted of her murder. He was in contact with mental health services delivered by Hertfordshire Partnership University NHS Foundation Trust and was previously a patient of Avon and Wiltshire Mental Health Partnership NHS Trust.

This independent review was undertaken alongside a Multi Agency Partnership Review into the death of Ms M in December 2015 which was commissioned by the Hertfordshire Adult Safeguarding Board.

Independent investigation into the care and treatment of patient M

Patient M killed his cellmate in HMP Peterborough and was subsequently convicted of manslaughter on the grounds of diminished responsibility. The investigation was conducted jointly with the Prison and Probation Ombudsman (PPO) investigation into the death in custody of M’s cellmate.

Independent review to follow up care provided for Mr Q at Hertfordshire Partnership University NHS Foundation Trust: November 2016

Independent report into the care of patient T: December 2015

Patient T was found hanged at his home in January 2013 and his wife M was found apparently suffocated. At the time Patient T was under the care of Hertfordshire Partnership NHS Foundation Trust (HPFT).

Independent investigation into the care and treatment of patient Y: December 2015

Patient Y was convicted of the murder of Mr Z in June 2011. The patient used services provided by South Essex Partnership University NHS Foundation Trust. Services have now transferred to East London NHS Foundation Trust.

Independent investigation into the care and treatment of Z: May 2015

This is the report of the independent investigation into the care and treatment of Patient Z. Prior to the event his care pathway involved four different trusts.

The following action plans are available:

Independent investigation into the care and treatment of P in Hertfordshire: May 2015

This is the report of the independent investigation into the care and treatment of Patient P.  Patient P was a well-known user of mental health services provided by Hertfordshire Partnership University NHS Foundation Trust (HPFT).

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

Independent Investigation into the care and treatment of X: October 2014

These are the full reports of the independent investigation into the care and treatment of X. X was found guilty of murder in January 2012. He had previously had contact with mental health services in Bedfordshire.

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

Independent investigation into the death of B: September 2014

This is the report of the independent investigation into the care and treatment of B who was killed by her husband A in 2011. A had previously had contact with mental health services in Suffolk.

The associated action plan has been published by Norfolk and Suffolk NHS Foundation Trust.

*Independent investigation into the care and treatment of Mr A: November 2013

This is the report of the independent investigation into the care and treatment of Mr A. At the time of the homicide (2010) Mr A was under the care of Hertfordshire Partnership NHS Foundation Trust.

The following action plans are available:

*Independent investigation into the care and treatment of Mr A: October 2013

This is the report of the independent investigation into the care and treatment of Mr A. Mr A was treated by Dacorum Community Mental Health Team, a service which is commissioned by Hertfordshire Partnership University NHS Foundation Trust.

*Independent investigation into the care and treatment of Mr X: August 2013

This is the report of the independent investigation into the care and treatment of Mr X. At the time of the homicide (2009) Mr X was under the care of Hertfordshire Partnership Foundation Trust.

The following action plans are available:

*Independent investigation into the care and treatment of Mr J: June 2013

This is the report of the independent investigation into the care and treatment of Mr J. At the time of the homicide (2010) Mr J was under the care of the former Suffolk Mental Health Partnership NHS Trust, which is now the Norfolk and Suffolk NHS Foundation Trust.

*Independent investigation into the care and treatment of Mr H: June 2013

This is the report of the independent investigation into the care and treatment of Mr H. At the time of the homicide (2010) 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.

*Independent investigation into the care of Mr A: March 2013

This is the report of the independent investigation into the care and treatment of Mr A. At the time of the homicide (2008) Mr A was under the care of the Cambridge and Peterborough NHS Foundation Trust.

The following documents are available: