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:

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.

Recognising and acting on signs of ‘county lines’ child exploitation: Published 21 November 2018

This is the case study commissioned by NHS England in relation to a young person W.

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 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 investigation into the care and treatment of mental health service user MB

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.

A joint Domestic Homicide Review and Independent Investigation into the care and treatment of ‘Dean’

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.

An independent investigation into the care and treatment of mental health service user Mr S

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 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.

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 investigation into the care and treatment of mental health service users (F and Maureen) in County Durham

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 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.

Independent investigation into the care and treatment of B

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

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

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

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 P

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 Mr A

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

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 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 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 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 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 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.

*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.

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 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 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 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.

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.