Independent investigation reports

Investigation Report into the NHS Care provided to the late Daniel Benfield in June 2016

NHS England published an investigation report into the NHS Care provided to the late Daniel Benfield in June 2016, who suffered from a sub-arachnoid haemorrhage.  The report sets out key findings and some recommendations for the organisations involved in his care.

Root Cause Analysis Investigation Report into the Death of Dr Julien Warshafsky

NHS England has published a Root Cause Analysis Investigation Report into the Death of Dr Julien Warshafsky. The focus of this case review is to explore opportunities for collective learning and identify actions that could be either considered or taken to minimise the risk of recurrence.

Independent Investigations 2019-21 Annual Report

NHS England assumed responsibility for the commissioning and oversight of Independent Investigations in 2013. The 2019-21 Annual Report of Independent Investigations has been published.

NHS England 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.

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.

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.