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:

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An independent review of the Independent Investigations for Mental Health Homicides in England (published and unpublished) from 2013 to 2017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 Mr H: Published September 2021

An independent investigation into the care and treatment of Mr H

This is the executive summary of the independent investigation report into the care and treatment of Mr H.  At the time of his death Mr H was receiving care from Lancashire and South Cumbria NHS Foundation Trust.

The Executive Summary has been published by:

An independent external quality assurance review of the independent investigation into the care and treatment of mental health service user Mr A: Published September 2021

This is the report of an assurance review of an independent investigation which considered the care and treatment of mental health service user Mr A in Greater Manchester

This is the report of an independent assurance review of an independent investigation which considered the care and treatment of mental health service user Mr A in Greater Manchester, published 2020.

An independent external assurance review report and associated assurance statement have been published by:

An independent external quality assurance review of the independent investigation into the care and treatment of mental health service user David: Published August 2021

An independent assurance review of the independent investigation into the care and treatment of mental health service user David

This is the report of an independent assurance review of an independent investigation which considered the care and treatment of mental health service user David at North West Boroughs Healthcare NHS Foundation Trust, published in June 2020.

The independent external assurance review report and associated assurance statement have been published by:

An independent external quality assurance review of the internal investigation into the care and treatment of mental health service user A : Published May 2021

An independent assurance review report into the care and treatment of mental health service user A

This is the report of an independent assurance review of North West Boroughs’ internal investigation which considered the care and treatment of mental health service user A

Mental health service user A was found guilty of manslaughter in May 2018.  He was ordered by the court to be detained under Section 37/41 of the Mental Health Act (1983) to remain in the medium secure hospital.

At the time of the homicide mental health service user A was receiving care and treatment from North West Boroughs Healthcare NHS Foundation Trust.

The independent external assurance review report and associated assurance statement have been published by:

North West Boroughs Healthcare NHS Foundation Trust

NHS Knowsley CCG

NHS St Helens CCG

An independent investigation into the care and treatment of David: Published June 2020

An independent investigation into the care and treatment of David. 

This is the executive summary of the independent investigation report into the care and treatment of David.  At the time of his death David was receiving care and treatment from North West Boroughs Healthcare NHS Foundation Trust.

The Executive Summary and associated action plans have been published by:

  • North West Boroughs Healthcare NHS Foundation Trust
  • NHS Wigan Boroughs CCG
  • NHS Knowsley CCG

Links to action plans are included and these will continue to be monitored for progress.

North West Boroughs Healthcare NHS Foundation Trust Action Plan

NHS Wigan Borough CCG Action Plan

NHS Knowsley CCG Action Plan

An independent investigation into the care and treatment of a mental health service user (Mr A) in Greater Manchester

This is the report of the independent investigation into the care and treatment of a mental health service user (Mr A).

Mr A was arrested and charged with murder in October 2017 and was later found guilty of manslaughter. Mr A was sentenced to an indefinite hospital order to treat his mental illness and has been detained in a secure hospital.

This report and associated action plan has been published by:

  • Greater Manchester Mental Health NHS Foundation Trust.

An action plan has been published by Greater Manchester Mental Health NHS Foundation Trust and can be found here

An independent investigation into the care and treatment of a mental health service user (Mr M) in Greater Manchester: Published February 2020

This is the report of the independent investigationto the care and treatment of mental health service user Mr M

This published report includes:

  1. an independent assurance review of the internal investigation and associated action planning into the care and treatment provided to a mental health service user Mr M in Greater Manchester
  2. a review of action plans developed by NHS funded organisations in response to the Serious Case Review that was commissioned by the Greater Manchester Multi Agency Public Protection Arrangements (MAPPA) Strategic Management Board

Mr M was convicted of the murder of a man in October 2017 whilst under the care of the Thomas project in Salford. The Thomas project provides a range of recovery focused services through detox and residential rehabilitation into community-based provision

An independent investigation into the care and treatment of MN: Published May 2019

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

MN was convicted of manslaughter in August 2017. At the time of the homicide MN was receiving care and treatment from Cheshire and Wirral Partnership NHS Foundation Trust.

The report has been published by:

  • Cheshire and Wirral Partnership NHS Foundation Trust
  • NHS South Cheshire CCG (now NHS Cheshire CCG)

This is the Assurance Review of the actions taken by Cheshire and Wirral Partnership NHS Foundation Trust and NHS Cheshire CCG

An independent investigation into the care and treatment of Mr L: Published 5 December 2018

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

An independent investigation into the care and treatment of mental health service user L in Greater Manchester : Published 28 November 2018

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

This is the Assurance Review of the actions taken by Greater Manchester Mental Health NHS Foundation Trust and Pennine Care NHS Foundation Trust, 12 months after publication of the independent investigation report.

An independent investigation into the care and treatment of Mr X: Published 11 June 2018

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

An independent investigation into the care and treatment of Mr W: Published 8 June 2018

This is the report of the independent investigation into the care and treatment of Mr W.  Mr W was convicted of the murder of Mr Dollery in June 2016.  At the time of the homicide Mr W was not in receipt of mental health services.  He had previously received care and treatment from Lancashire Care NHS Foundation Trust (community mental health services) and Inspire (substance misuse services).

The independent investigation report has also been published by:

  • Lancashire Care NHS Foundation Trust
  • NHS Blackburn with Darwen CCG

An action plan has been published by Lancashire Care NHS Foundation Trust and can be found here.

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

 

A joint Domestic Homicide Review and Independent Investigation into the care and treatment of ‘Dean’: Published 26 January 2018

This is the joint Domestic Homicide and Independent Investigation in to the care and treatment of ‘Dean’, commissioned by Sefton Safer Communities Partnership and NHS England (North).

The associated action plans have been published by Sefton Safer Communities Partnership and Mersey Care NHS Foundation Trust.

Combined Serious Case Review and NHS England Mental Health Homicide Review – Child D: Published October 2017

This is the Independent Review undertaken on behalf of Stockport Safeguarding Children Board and NHS England in to the death of Child D.  The Chair of Stockport Safeguarding Children Board took the decision to convene a serious case review in Sept 2015 and commissioned an independent author. NHS England, North Region commissioned an independent review into the care and treatment of the Child D’s father. The Verita team authored Chapter 11 of this report.

An independent investigation into the care and treatment of Mr S: Published September 2017

This is the report of the independent investigation into the care and treatment of Mr S. Mr S was convicted of the murder of Mrs S in 2014. At the time of the homicide Mr S was receiving care and treatment from Lancashire Care NHS Foundation Trust.

The report and associated action plans have been published by:

Blackburn and Darwen CCG have published the report and will monitor the Lancashire Care NHS Foundation Trust action plan until fully implemented.

An independent inquiry into the care and treatment of S: Published August  2017

This is an independent investigation into the care and treatment of S who was convicted of manslaughter on the grounds of diminished responsibility.

At the time of the homicide (2014), S was receiving mental health services provided by Mersey Care NHS Foundation Trust.

The action plan is available via the Mersey Care NHS Foundation Trust website.

An independent external quality assurance review (published 20 December 2018) can be viewed here.

Independent investigation into the care and treatment of B: Published 5 April 2017

This is the report of the independent investigations into the care and treatment of B.  At the time of homicide March 2015 B was receiving care and treatment from Pennine Care NHS Foundation Trust.

The associated plans have been published by the relevant Trusts:

Independent investigation into the care and treatment of Mr DB: Published 13 December 2016

This is the report of the independent investigations into the care and treatment of Mr DB.  At the time of homicide December 2014 Mr DB was receiving care and treatment from Pennine Care NHS Foundation Trust.

The associated plans have been published by the relevant Trusts and CCG:

Independent investigation into the care and treatment of Mr P: Published 10 June 2016

This is the independent investigation into the care and treatment of Mr P, who attacked and killed a 17-year-old man on 1 January 2015.  At the time of the death Mr P was receiving mental health services provided by 5 Boroughs Partnership NHS Foundation Trust.

The associated action plans have been published by the relevant trusts:

Independent investigation into the care and treatment of Patient R: January 2015

This is the independent investigation into the care and treatment of Patient R, who committed a homicide in April 2011. At the time of the death Patient R was receiving mental health services provided by 5 Boroughs Partnership NHS Foundation Trust and Mersey Care NHS Trust.

The associated action plans have been published by the trusts:

*Independent investigation into the care and treatment of Mr Y: December 2014

This is the report and executive summary of the independent investigation into the care and treatment of Mr Y. Mr Y received care and treatment for his mental health condition from Mersey Care NHS Trust and Imagine Independence (a mental health charity).

The associated action plan has been published by Mersey Care NHS Trust.

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

This is the report of the independent investigation into the care and treatment of Mr G. Mr G received care and treatment for his mental health condition from Lancashire Care NHS Foundation Trust.

The associated action plan has been published by Lancashire Care NHS Foundation Trust.

Independent investigation into the care and treatment of Mr B and Ms C: November 2014

This is the report of the independent investigation into the care and treatment of Mr B and Ms C. At the time of the homicide (2012) Mr B and Ms C were receiving care from Mersey Care NHS Trust.

The associated action plan has been published by Mersey Care NHS Trust.

Independent investigation into the care and treatment of Mr M: September 2014

This is the report of the independent investigation into the care and treatment of Mr M. At the time of the homicide (2013) Mr M was receiving care and treatment from Mersey Care NHS Trust.

The associated action plan has been published by Mersey Care NHS Trust.

An Independent investigation into the care and treatment of Patient E (Case Ref: 2011/2424): March 2014

This is the report of the independent investigation into the care and treatment of Patient E.  At the time of the death (2011) Patient E was receiving mental health services provided by Pennine Care NHS Foundation Trust.

The associated action plan has been published by the trust.

*Independent investigation into the care and treatment of Mr F: December 2013

This is the report of the independent investigation into the care and treatment of Mr F. At the time of the homicide (2011) Mr F was receiving mental health services provided by Lancashire Care NHS Foundation Trust.

The associated action plan has been published by the trust.

*Independent investigation into the care and treatment of Miss E: December 2013

This is the report of the independent investigation into the care and treatment of Miss E. At the time of the homicide (2011) Miss E was receiving mental health services provided by Lancashire Care NHS Foundation Trust.

The associated action plan has been published by the trust.

*Independent investigation into the care and treatment of Mr W: December 2013

This is the report of the independent investigation into the care and treatment of Mr W. At the time of the homicide (2006) Mr W was receiving mental health services provided by Merseycare NHS Foundation Trust.

Independent investigation into the care and treatment of Mr Z: November 2013

This is the report of the independent investigation into the care and treatment of Mr ZAt the time of the homicide (2010) Mr Z was under the care of the Manchester Mental Health and Social Care NHS Trust.

Independent investigation into the care and treatment of Mr A: August 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 receiving mental health services provided by Cheshire and Wirral Partnership Trust.

The associated action plan has been published by the trust.