Independent investigation reports

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.

In April 2013 NHS England became responsible for commissioning independent investigations into homicides (sometimes referred to as mental health homicide reviews) that are committed by patients being treated for mental illness. The portfolio, remit and capacity of each commissioning regional team differs slightly, however the common function is to manage and oversee the Independent Investigation function on behalf of NHS England. Regional teams may also commission a number of Patient Safety System wide investigations, including non-mental health homicide investigations.

NHS England assumed responsibility for the commissioning and oversight of Independent Investigations in 2013.

An independent review of the care and management of Mr F: Published August 2022

This is the independent quality assurance review of the care and management of Mr F.

South West Yorkshire Partnership NHS Foundation Trust has also published an assurance statement into this case.

An independent review into the care and treatment of Mr G between 2014-2019: Published May 2022

This is the extended executive summary of the independent investigation into the care and treatment of Mr G.

South West Yorkshire Partnership NHS Foundation Trust has also published an assurance statement into this case.

A Joint Domestic Homicide Review and independent mental health homicide investigation in January 2019, West Cumbria: Published May 2022

This is the Joint Domestic Homicide Review and independent mental health homicide investigation in January 2019, West Cumbria.

West Cumbria Community Safety Partnership has published an associated action plan which can be found here.

An independent investigation into the care and treatment of mental health service user Mr G: Published 30 March 2022

This is the extended executive summary of the independent investigation into the care and treatment of Mr G.

Bradford District Care NHS Foundation Trust has also published an assurance statement into this case.

An independent investigation into the care and treatment of Mr A: Published February 2022

This is the executive summary of the independent investigation into the care and treatment of Mr A.

South West Yorkshire Partnership NHS Foundation Trust has also published an assurance statement into this case.

The 2019-21 Annual Report of Independent Investigations has been published.

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.

An independent investigation into the care and treatment of a mental health service user Mr D in the North East: Published October 2021

This is the report of the independent investigation into the care and treatment of Mr D.

The associated action plan has been published by Tees, Esk and Wear Valleys NHS Foundation Trust.

An independent investigation into the care and treatment of a mental health service user Ms C in Humber Teaching NHS Foundation Trust: Published July 2021

This is the report of the independent investigation into the care and treatment of Ms C.

An independent quality assurance review of the implementation of recommendations resulting from this independent investigation was published in August 2022 and is available here.

An independent external quality assurance review following an internal investigation into the care and treatment of mental health service user A in Northumberland, Tyne and Wear NHS Foundation Trust. Published June 2021

This is the independent external quality assurance review following an internal investigation into the care and treatment of A.

A post-publication assurance review in relation to the implementation of recommendations resulting from the investigation into the homicide committed by a mental health service user, A, can be viewed here.

An independent investigation into the care and treatment of Mr M. Published May 2021

This is the executive summary of an independent investigation into the care and treatment of Mr M.

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.

An independent investigation into the care and treatment of a mental health service user A in NAViGO: Published March 2020

This is the report of the independent investigation into the care and treatment of a mental health service user A in NAViGO.

An independent investigation assurance review (published June 2021) can be viewed here.

An independent investigation into the care and treatment of Jack by Rotherham Doncaster and South Humber NHS Foundation Trust: Published February 2020

This is the abridged executive summary of the independent investigation into the care and treatment of Jack.

An independent quality assurance review (published August 2021) can be viewed here.

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 has 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.

Section one: Executive Summary
Section two: Main report

An independent investigation into the care and treatment of two mental health service users Mr A and Mr O in Lincolnshire: Published 9 September 2019

This is the report of the independent investigation into the care and treatment of two mental health service users Mr A and Mr O.

This is the Independent Quality Assurance Review of Mr A and Mr O following an investigation into the care and treatment of Mr A and Mr O. Published 3 August 2021.

An independent investigation into the care and treatment of Harry Bosomworth by Leeds and York Partnership NHS Foundation Trust and The Leeds Teaching Hospitals NHS Trust: Published 18 December 2018

This is the report of the independent investigation into the care and treatment of Harry Bosomworth.

An independent investigation into the care and treatment of MS: Published 14 November 2018

This is the report of the independent investigation into the care and treatment of MS.

Assurance statements and/or reports have been published by:

An independent investigation into the care and treatment of Ms K: Published 7 November 2018

This is the report of the independent investigation into the care and treatment of Ms K.

Assurance statements and/or reports have been published by:

An independent investigation into the care and treatment of Thomas: Published 23 July 2018

This is the report of the independent investigation into the care and of Thomas.

An independent investigation into the care and treatment of mental health service user MB: Published 19 March 2018

This is the independent investigation into the care and treatment of mental health service user MB. At the time of the offence MB was receiving mental health services provided by Harrogate Health Care NHS Trust.

The associated assurance report has been published by Tees, Esk and Wear Valleys NHS Foundation Trust which is the current provider of these services in Harrogate.

NHS England has also published an assurance statement into this case.

An independent investigation into the care and treatment of mental health service user Mr S: Published 23 November 2017

This is the independent investigation into the care and treatment of mental health service user Mr S. At the time of the offence Mr S was receiving mental health services provided by Tees, Esk and Wear Valleys NHS Foundation Trust.

The associated action plan has been published by Tees, Esk and Wear Valleys NHS Foundation Trust.

An independent external quality assurance review (published November 2019) can be viewed here.

An independent investigation into the care and treatment of Patient A and Patient B: Published November 2017

This is the executive summary of an independent investigation report into the care and treatment of Patient A and Patient B.

An action plan has been published by Cygnet Health Care and can be found on the their website.

An independent investigation into the care and treatment of Miss B: Published October 2017

This is the independent investigation report into the care and treatment of Miss B. Miss B was convicted of murder in December 2015.

At the time of the homicide Miss B was receiving care and treatment from Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH).

An action plan has been published by RDaSH and can be found on the their website.

An independent investigation into the care and treatment of mental health service users (F and Maureen) in County Durham: Published 6 September 2017

This is the independent investigation into the care and treatment of mental health service users (F and Maureen) in County Durham. F and Maureen were patients on Picktree Ward, a mental health service for older people (MHSOP) ward in the Bowes Lyon Unit at Lanchester Road Hospital, County Durham, provided by Tees Esk and Wear Valleys NHS Foundation Trust.

On 19 May 2015, an incident occurred between Maureen and F which resulted in F pushing Maureen from behind resulting in her falling to the ground.  Maureen subsequently died on 25 May 2015.

The associated action plan has been published by Tees Esk and Wear Valleys NHS Foundation Trust.

An independent external quality assurance review (published November 2019) can be viewed here.

Independent investigation into the care and treatment of MR: Published 28 November 2016

This is the independent investigation into the care and treatment of MR, who was involved in an incident with another resident at a care home. MR was in receipt of mental health services provided by Tees, Esk and Wear Valleys NHS Foundation Trust.

The associated NHS action plans have been published by North Durham Clinical Commissioning Group and Tees, Esk and Wear Valleys NHS Foundation Trust.

Independent investigation into the care and treatment of Ms A: Published 22 June 2016

This is the independent investigation into the care and treatment of Ms A, who killed Mr O on 22 February 2013.  At the time of the death Ms A was receiving mental health services provided by Tees, Esk and Wear Valleys NHS Foundation Trust.

The associated action plans have been published by the relevant CCG and Trust.

Independent investigation into the care and treatment of Mr A: Published 3 February 2016

This is the independent investigation into the care and treatment of Mr A, who stabbed and killed his wife. Mr A then committed suicide.

At the time of the murder, Mr A was receiving mental health services provided by Northumberland, Tyne and Wear NHS Foundation Trust.

The associated action plan has been published by Northumberland, Tyne and Wear NHS Foundation Trust.

Independent investigation into the care and treatment of Mr B: Published 29 January 2016

This is the independent investigation into the care and treatment of Mr B, who was found guilty of murder and sentenced to life imprisonment after killing Mr X.

At the time of the murder, Mr B was receiving mental health services provided by Northumberland, Tyne and Wear NHS Foundation Trust.

The associated action plan has been published by Northumberland, Tyne and Wear NHS Foundation Trust.

Independent investigation into the care and treatment of Mr E: March 2015

This is the Independent Investigation into the care and treatment of Mr E, who was convicted of the murder of Victim ND.

At the time of the death Mr E was receiving mental health services provided by Northumberland, Tyne and Wear NHS Foundation Trust.

The associated action plan has been published by Northumberland, Tyne and Wear NHS Foundation Trust.

Independent investigation into the care and treatment of Mr F: March 2015

This is the independent investigation into the care and treatment of Mr F, who was found guilty of two murders and received two life sentences with a minimum term of 37 years.

At the time of the murders, Mr F was receiving mental health services provided by Tees, Esk and Wear Valleys NHS Foundation Trust.

The associated action plan has been published by Tees, Esk and Wear Valleys NHS Foundation Trust.

*Independent investigation into the care and treatment of Mr J: November 2014

This is the report of the independent investigation into the care and treatment of Mr J. At the time of the incident (2010) Mr J had been receiving support from a community mental health team at South West Yorkshire Partnership NHS Foundation Trust.

The associated action plans have been published by South West Yorkshire Partnership NHS Foundation Trust.

The former North of England Strategic Health Authority (SHA) agreed to commission these investigations alongside a thematic review which also incorporated three earlier investigations. The SHA was abolished prior to the reports being commissioned.

*Independent investigation into the care and treatment of Mr L: November 2014

This is the report of the independent investigation into the care and treatment of Mr. L. At the time of the incident (2011) Mr L had three brief episodes of care with South West Yorkshire Partnership NHS Foundation Trust.

The associated action plans (these documents are no longer available online) have been published by South West Yorkshire Partnership NHS Foundation Trust.

The former North of England Strategic Health Authority (SHA) agreed to commission these investigations alongside a thematic review which also incorporated three earlier investigations. The SHA was abolished prior to the reports being commissioned.

*Independent investigation into the care and treatment of Mr N: October 2014

This is the report of the independent investigation into the care and treatment of Mr N. At the time of the incident (2011) Mr N was not in receipt of mental health services.

The associated action plans (these documents are no longer available online) have been published by South West Yorkshire Partnership NHS Foundation Trust.

The former North of England Strategic Health Authority (SHA) agreed to commission these investigations alongside a thematic review which also incorporated three earlier investigations. The SHA was abolished prior to the reports being commissioned.

Independent investigation into the care and treatment of Patient L: October 2014

This is the executive summary of the independent investigation into the care and treatment of Patient L. At the time of the homicide (2011) Patient L was receiving community mental health services provided by Sheffield Health and Social Care NHS Foundation Trust.

The associated action plan has been published by the trust.

*Independent investigation into the care and treatment of Patient E: June 2014

This is the executive summary of the independent investigation into the care and treatment of Patient E. At the time of the homicide (2008) Patient E was receiving mental health services provided by Northumberland, Tyne and Wear NHS Foundation Trust.

The associated action plan arising from the investigation is also available.

*Independent investigation into the care and treatment of Patient 2009/3245: January 2014

This is the report of the independent investigation into the care and treatment of Patient 2009/3245. At the time of the homicide Patient 2009/3245 (2009) was receiving mental health services provided by Tees, Esk and Wear Valleys NHS Foundation Trust.

The associated action plan is also available.

*Independent investigation into the care and treatment of Patient G: December 2013

This is the report of the independent investigation into the care and treatment of Patient G. At the time of the homicide (2009) Patient G was receiving mental health services provided by Northumberland, Tyne and Wear NHS Foundation Trust.

The associated action plan has been published by the trust.

*Independent investigation into the care and treatment of Patient C: November 2013

This is the report of the independent investigation into the care and treatment of Patient C. At the time of the homicide (2007) Patient C was receiving mental health services provided by Northumberland, Tyne and Wear NHS Foundation Trust.

The associated action plan has been published by the trust.

*Independent investigation into the care and treatment of Patient I: November 2013

This is the report of the independent investigation into the care and treatment of Patient I. At the time of the homicide (2010) Patient I was receiving mental health services provided by Northumberland, Tyne and Wear NHS Foundation Trust.

The associated action plan has been published by the trust.