Independent investigation reports for London

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 Assurance Review – Mr X

This is the independent assurance review for Mr X published on 4th April 2022.

Mr X was in receipt of services in South West London.

Independent investigation into the care and treatment of Mr N and Mr G

This is the independent investigation report into the care and treatment of Mr N and Mr G published on 21st February 2022.

Mr N and Mr G were in receipt of services in North London.

Independent investigation into the care and treatment of Mr N

This is the independent investigation report into the care and treatment of Mr N published on the 10th February 2022.

Mr N was in receipt of services in West London.

Independent investigation into the care and treatment of Mr A and Mr B

This is the independent investigation report into the care and treatment of Mr A and Mr B on the 31st January 2022.

Mr A and B were in receipt of services from South West London and St George’s Mental Health NHS Trust.

Independent review of the care and treatment of Mr X

This is the independent investigation report into the care and treatment of Mr X published on the 26th January 2022.

Mr X was in receipt of services from East London Foundation Trust.

Independent Investigations 2019/21 Annual Report

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: Independent Investigations 2019-21 Annual Report (December 2021)

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

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

Independent review of the care and treatment of Mr G

This is the independent investigation report into the care and treatment of Mr G published on the 16th November 2021.

Mr G was in receipt of services from Barnet, Enfield and Haringey Mental Health NHS Trust.

Independent investigation into the care and treatment of Mr L

This is the independent investigation report into the care and treatment of Mr L who committed a homicide in June 2013.

Mr L was in receipt of services from East London NHS Foundation Trust.

Independent investigation into the care and treatment of User A

This is the independent investigation report into the care and treatment of User A, published on 8th September 2021.

User A was in receipt of services from North East London NHS Foundation Trust and North East London CCG.

Independent investigation into the care and treatment of Mr X

This is the independent investigation report into the care and treatment of Mr X, published on 25th August 2021.

Mr X was in receipt of services from South London and Maudsley NHS Foundation Trust.

Independent investigation into the care and treatment of Mr S

This is the independent investigation report into the care and treatment of Mr S, published on 16th December 2020.

Mr S was in receipt of services from Central North West London NHS Trust.

Independent investigation into the care and treatment of Mr Z

This is the independent investigation report into the care and treatment of Mr Z, published on 8th October 2020.

Mr Z was in receipt of services from West London NHS Trust.

Independent investigation into the care and treatment of Mr J

This is the independent investigation report into the care and treatment of Mr J, published on 25 August 2020.

Mr J was in receipt of services from South London and Maudsley NHS Trust.

Independent Investigations 2018-19 Annual Report

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

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

Independent investigation into the care and treatment of Mr B and Ms A

This is the independent investigation report into the care and treatment of Mr B and Ms A, published on 13 November 2019.

Mr B and Ms A were in receipt of services from Central and North West London NHS Foundation Trust

Independent investigation into Mental Health Homicides 2013-2017

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.

• External review of internal investigation reports for Mental Health Homicides 2013-2017
Executive summary

Independent investigation into the care and treatment of Mrs A and Miss B

This is the independent investigation report into the care and treatment of Mrs A and Miss B, published on 03 July 2019.

Mrs A and Miss B was in receipt of services from Oxleas NHS Foundation Trust.

Independent investigation into the care and treatment of Mr H

This is the independent investigation report into the care and treatment of Mr H who committed a homicide in 2014, published on 10 April 2019.

Mr H was in receipt of services from South West London & St George’s NHS Mental Health Trust and Merton CCG.

Independent investigation into the care and treatment of Mr R

This is the independent investigation report into the care and treatment of Mr R who committed a homicide in 2012, published on 28 February 2019.

Mr R was in receipt of services from South West London & St George’s NHS Mental Health Trust.

Independent investigation into the care and treatment of Mr J

This is the independent investigation report into the care and treatment of Mr J who committed a homicide in 2014.

Mr J was in receipt of services from East London NHS Foundation Trust and Newham CCG.

Independent investigation into the care and treatment of DO

This is the independent investigation report into the care and treatment of DO who committed a homicide in 2013.

DO was in receipt of services from South London and Maudsley NHS Foundation Trust and NHS Croydon CCG.

Independent investigation into the care and treatment of Mr S

This is the independent investigation report into the care and treatment of Mr S who committed a homicide in 2013.

Mr S was in receipt of services from Central and North West London Trust.

Independent investigation into the care and treatment of Mr E

This is the independent investigation report into the care and treatment of Mr E who committed a homicide in 2012.

Mr E was in receipt of services from South London and Maudsley NHS Foundation Trust.

Independent investigation into the care and treatment of Mr L

This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014.

Mr L was in receipt of services from Oxleas NHS Foundation Trust.

Independent investigation into the care and treatment of Mr B

This is the independent investigation report into the care and treatment of Mr B who committed a homicide in 2012.

Mr B was in receipt of services from South London and Maudsley NHS Foundation Trust.

Independent investigation into the care and treatment of Mr G

This is the independent investigation report into the care and treatment of Mr G who committed a homicide in 2012.

Mr G was in receipt of services from Camden and Islington NHS Foundation Trust.

Independent investigation into the care and treatment of Mr J

This is the independent investigation report into the care and treatment of Mr J who committed a homicide in 2014.

Mr J was in receipt of services from South London and Maudsley NHS Foundation Trust.

Independent investigation into the care and treatment of Mr X

This is the independent investigation report into the care and treatment of Mr X who committed a homicide in 2013.

Mr X was in receipt of services from Oxleas NHS Foundation Trust.

Independent investigation into the care and treatment of Mr L

This is the independent investigation report into the care and treatment of Mr L who committed a homicide in June 2013.

Mr L was in receipt of services from East London NHS Foundation Trust.

Independent investigation into the care and treatment of Mr EF

This is the independent investigation report into the care and treatment of Mr EF who committed a homicide in May 2014.

Mr EF was in receipt of services from Barnet, Enfield and Haringey Mental Health NHS Trust.

Independent investigation into the care and treatment of Mr T

This is the independent investigation report into the care and treatment of Mr T who committed a homicide in May 2014.

Mr T was in receipt of services from Camden and Islington NHS Foundation Trust.

This version replaces the one originally published on 7 July 2017 as Recommendation 5 was incorrectly allocated.

Independent investigation into the care and treatment of Ms A

This is the independent investigation report into the care and treatment of Ms A who committed a homicide in October 2011.

Ms A was in receipt of services from Oxleas NHS Foundation Trust.

Independent investigation into the care and treatment of Mr X and Mr Y

This is the independent investigation report into the care and treatment provided to Mr X and Mr Y.

Independent investigation into the care and treatment of Mr S

This is the independent investigation report into the care and treatment of Mr S who committed a homicide in November 2012.

Mr S had previously received treatment from Central and North West London NHS Foundation Trust and West London Mental Health Trust.

Independent investigation into the care and treatment of Mr I

This is the independent investigation report into the care and treatment of Mr I who committed a homicide in April 2012.

At the time of the death, Mr I was in receipt of mental health service from Central and North West London NHS Foundation Trust, he was residing at St Mungo’s Broadway and receiving support from Turning Point.

Independent investigation into the care and treatment of Mr Q: April 2015

This is the report of the independent investigation into the care and treatment of Mr Q. Mr Q had recently been discharged from Barnet, Enfield and Haringey Mental Health NHS Trust (BEH) at the time of the death.

The associated action plan has been published by Barnet, Enfield and Haringey Mental Health NHS Trust.

Independent investigation into the care and treatment of Mr DE: July 2014

This is the report of the independent investigation into the care and treatment of Mr DE. At the time of the homicide (2011) Mr DE was in receipt of psychiatric services provided by South London and Maudsley NHS Foundation Trust.

The associated action plan has been published by the trust.

Independent investigation into the care and treatment of Mr C and Mr D: December 2013

This is the report of the independent investigation into the care and treatment of Mr C and Mr D. At the time of the homicide (2011) they were both in receipt of psychiatric services provided by Camden and Islington NHS Foundation Trust.

The associated action plan has been published by both trusts