Independent investigation reports for Midlands

Independent Investigation 2018 – 2019 Annual Report

NHS England assumed responsibility for the commissioning and oversight of Independent Investigations in 2013. The 2018-19 Annual Report of Independent Investigations has now been published.

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 our 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 Report into the Care and Treatment of Mr N in Derbyshire

Mr N was released from prison whilst detainable, but no suitable bed could be found.  Mr N approached a policeman saying he was hearing voices telling him to kill people.  The policeman took him to the local Emergency Department where he spent two days waiting for a bed.  He was transferred to an Enhanced Care Ward and placed in seclusion, before his transfer into higher secure services after a couple of weeks.

This was a near miss and investigated due to the potential for learning across systems.

An independent review of the Independent Investigations for Mental Health Homicides in England (published and unpublished) from 2013 to 2017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


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 the Delivery by Derbyshire NHS Foundation Trust of Action Plans Following Two Historical SUIs in the North Midlands

Patient Ms Z was convicted of manslaughter with diminished responsibility. Patient Mr S killed victim 1 and victim 2 and then took his own life. Both patients had been in contact with mental health services delivered by Derbyshire Healthcare NHS Foundation Trust.

The independent quality assurance review was commissioned by NHS England to review progress against the recommendations and actions identified as part of the independent investigations which were published in July 2017 and September 2017 respectively.

Independent External Quality Assurance Review following the independent investigation into the care and treatment of P in the West Midlands

P was charged with the murder of Christina in 2013.

The independent External Quality Assurance Review was commissioned by NHS England to review progress against the recommendations and actions identified as part of the independent investigation which was published in June 2017.

All future updates on progress will be published by the individual organisations concerned.

Independent Care and Treatment Review into the care and treatment provided to Mr AS

Patient Mr AS took his life in October 2013 following a long and complex history of mental health illness. The purpose of the review was to fully consider the care and treatment provided to Mr AS and to make recommendations for further action where appropriate.

Independent External Quality Assurance Review in respect of Mental Health Service Users Mr A and Mr B.

Patient Mr A was charged and convicted of murdering his mother on 3 July 2012. Patient Mr B was charged and convicted of murdering his mother on 20 July 2011.

The independent External Quality Assurance Review was commissioned by NHS England, to review the outcomes of the Birmingham and Solihull Mental Health NHS Foundation Trust’s (BMHFT) internal review and the Birmingham Community Safety Partnership’s Domestic Homicide Review following the two homicides.

Independent investigation into the care and treatment of Mr S in the North Midlands

Patient Mr S killed victim 1 and victim 2 and then committed suicide. He had been in contact with mental health services delivered by Derbyshire Healthcare NHS Foundation Trust.

Independent investigation into the care and treatment of Ms Z in the North Midlands

Patient Ms Z was convicted of manslaughter with diminished responsibility of the victim. She had previously been in contact with mental health services delivered by Derbyshire Healthcare NHS Foundation Trust.

Independent investigation into the care and treatment of P in the West Midlands: June 2017

Patient P was convicted of manslaughter with diminished responsibility of Christina. He had previously been in contact with mental health services and prison mental health services in the West Midlands.

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

Patient H was convicted of convicted of manslaughter with diminished responsibility of Mrs H. At the time of the death patient H was under the care of Birmingham and Solihull Mental Health NHS Foundation Trust.

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

Patient X was convicted of convicted of manslaughter with diminished responsibility of Ms Y. At the time of the death patient X was under the care of South Staffordshire Shropshire Healthcare NHS Foundation Trust.

Independent investigation into the care and treatment of patient K: November 2015

Patient K was convicted of the murder of Jane Edwards. At the time of the death patient K was under the care of South Staffordshire Shropshire Healthcare NHS Foundation Trust.

The following action plan from South Staffordshire and Shropshire Healthcare NHS Foundation Trust is available.

*Independent investigation into the care and treatment of Mr R: May 2012

This is the report of the independent investigation into the care and treatment of Mr R. At the time of the homicide Mr R was under the care of Northamptonshire Healthcare NHS Foundation Trust. Mr R had previously had contact with Nottinghamshire Healthcare NHS Trust.

The following action plans are available: