Independent investigation reports

South West

Independent Investigations 2019/21 Annual Report

December 2021

The 2019/2021 annual report provides an overview of independent investigations commissioned by regional independent investigation teams, which primarily relate to homicides committed by those in receipt of mental health services.

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 report details the key findings from the investigations and the performance of the commissioning arrangements.

Investigations in the South West are reported jointly with South East.

Independent Investigations 2018/19 Annual Report

NHS England assumed responsibility for the commissioning and oversight of independent investigations in 2013.  The 2018/19 Annual Report of Independent Investigations has been published today (30 July 2020) 

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.

2018 2019 Independent Investigation Annual Report

 

External review of all Independent Investigations following Mental Health Homicides

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 have 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.