Independent investigation reports for Midlands and East

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

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 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 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 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 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 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:

*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: