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.

Independent review of care by Norfolk and Suffolk Mental Health NHS Foundation Trust – October 2024

This independent review report has been commissioned by NHS England relating to the care provided by Norfolk and Suffolk Mental Health NHS Foundation Trust for an individual who was responsible for the death of their grandmother.

This report aims to strengthen local services in the context of the evidence and relevant information about the incident. The report supports learning and informs the NHS and the public on future service provision.

 

Key findings and action plan – Final report: Norfolk and Suffolk NHS Foundation Trust: Early intervention in psychosis team pathway review – June 2023

This report was commissioned by the trust and made twelve recommendations to improve the care and treatment of service users, and three recommendations to improve practice following a serious incident.

The investigation was prompted by the death of an 84-year-old gentleman who had been walking his dog in a remote wooded area in Norfolk by a 23-year old man. At the time of the homicide the young man was not under the care of mental health services, but he had had three previous episodes of care provided by Norfolk and Suffolk NHS Foundation Trust (NSFT or ‘the Trust’).

 

Independent investigation into the care and treatment of Mr M – August 2021

This investigation was commissioned by NHS England and was conducted in partnership with the Domestic Homicide Review which was commissioned by Southend, Essex and Thurrock Domestic Abuse Board.

The investigation was prompted by the death of a woman in Essex in 2020. The purpose of the investigation was to help the NHS and partners understand if there are lessons that could be learned that could prevent something similar happening in the future.

 

Independent investigation into the care and treatment of Mr D – January 2022

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

Mr D had a diagnosis of paranoid schizophrenia and recurrent depressive disorder. He was a recipient of mental health services provided by Cambridgeshire and Peterborough NHS Foundation Trust.

On 27 November 2019 Mr D attacked Miss Y, another resident, in the common room of their supported accommodation. Miss Y sadly died later the same day. Mr D was found guilty of murder and sentenced to a minimum of 15 years in February 2021. Sincere condolences are offered to all the people who have been affected by this tragic event.

An independent investigation report, commissioned by NHS England – East of England, into the care and treatment Mr D received is published below, alongside a Safeguarding Adult Review into the death of Miss Y which was commissioned by the Cambridgeshire and Peterborough Safeguarding Adults Partnership Board.

NHS England – East of England commissioned this independent investigation which follows 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 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 are required which could help prevent similar incidents occurring.

Independent investigations annual report 2019-21

NHS England assumed responsibility for the commissioning and oversight of Independent Investigations in 2013. The 2019-21 annual report of independent investigations has been published here.

NHS England Independent Investigation Governance Committee (IIGC) are responsible for the commissioning of the Annual Report. The IIGC made the decision not to publish an Annual Report of 2019/20 in 2020 due to the pressures on the NHS during the COVID-19 pandemic. However, when pressures eased the IIGC made the decision to conduct an Annual Report which was inclusive of both financial years 2019/20 and 2020/21.

The 2019-21 annual report details the findings and performance of commissioning of Independent Investigations, which primarily relate to homicides committed by those in receipt of mental health services. Independent investigations commissioned under the Serious Incident Framework (2015) ensure that mental health care-related homicides are investigated in such a way that effective learning can be identified, and changes implemented to minimise the risk of recurrence.

NHS England has accepted the report findings and recommendations which will inform regional and national workplans to influence system improvements.

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

 

An independent investigation into the care and treatment of Mr Q – 2020

The Learning Document from the independent investigation into the circumstances surrounding the care and treatment of Mr Q are published on this webpage:

 

An independent investigation into the care and treatment of Mr Z – July 2021

The findings of an independent investigation into the circumstances surrounding the care and treatment of Mr Z are published on this webpage:

Essex Partnership University Trust and NHS Thurrock ICS, which are cited in the report’s recommendations, have also published an action plan an action plan in response to the findings.

An independent investigation into the NHS care and treatment of Mother in Essex – December 2020

The findings of an independent investigation into the circumstances surrounding the care and treatment of Mother in Essex are published on this webpage. Mother had been under the care of secondary mental health services since March 2017.

Following the homicide of Child R by his Mother in July 2018, NHS England  commissioned an independent investigation into the care and treatment of mental health service user, Mother.

An independent investigation into Mother and a related serious case review into Child R are available at the links below:

Essex Partnership University Trust, which is cited in the independent investigation report, has also published an action plan in response to the findings.

 

An independent investigation into the care and treatment of a mental health service user James in Essex – November 2020

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

James killed his long-term girlfriend in December 2017. He had been a patient of North Essex Partnership Trust (NEPT), now Essex Partnership University Trust (EPUT) since 2000.

A joint Independent Investigation and Domestic Homicide Review has taken place and both reports are available below:

Essex Partnership University Trust, which is cited in the independent investigation report, has also published an action plan in response to the findings.

Independent investigations annual report 2018-19

NHS England assumed responsibility for the commissioning and oversight of independent investigations in 2013.  2018 2019 Independent Investigation Annual Report has been published today.

The 2018-19 annual report details the findings and performance of commissioning of independent investigations, which primarily relate to homicides committed by those in receipt of mental health services. Independent investigations carried out under the serious incident framework (2015) ensure that mental health care-related homicides are investigated in such a way that effective learning can be identified, and changes implemented to minimise the risk of recurrence.

NHS England has accepted the report findings which will inform regional and national workplans to influence system improvements.

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

 

An independent investigation into the care and treatment of a mental health services user ‘Mr P’ in Essex – June 2020

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.

NHS England – 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.

Essex Partnership University Trust, which is cited in the independent investigation report, has also published an action plan in response to the findings.

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.

Independent Quality Assurance Review – Norfolk and Suffolk NHS Foundation Trust 

The independent assurance review provides an assessment of the implementation of the actions developed in response to recommendations from the independent investigation into the care and treatment of Mr K in Suffolk.

An independent investigation into the care and treatment of a mental health service user (Tom) in Cambridgeshire – September 2019

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 – January 2018

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.

In 2019, NHS England commissioned an assurance review to look at progress made by Hertfordshire Partnership University NHS Foundation Trust to make improvements to services since the publication of the Independent Review into the NHS Care and Treatment Provided to Mr O. This report was published in November 2020:

Independent investigation into the care and treatment of patient M – March 2017

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: