Devon Partnership NHS Trust

An independent investigation into the care and treatment of Mr A in Devon

This review should be read in conjunction with the report below, ‘Multi-agency systems review to identify the learning following five homicides in Devon (2018-2019); with a focus on mental health care and management in custody’

NHS England has published a mental health homicide review into the care and treatment of Mr A, who was a service-user under Avon and Wiltshire Mental Health Partnership NHS Foundation Trust, Devon Partnership NHS Trust and Cygnet Health Care between June 2016 and December 2017. Mr A went on to kill three elderly men in their homes in Exeter in February 2019.

Devon Partnership NHS Trust and NHS Devon have both published a joint action plan on their websites, in response to the report’s recommendations.

The action plans are available at:

Multi-agency systems review to identify the learning following five homicides in Devon (2018-2019); with a focus on mental health care and management in custody

This review should be read in conjunction with the report above, ‘An independent investigation into the care and treatment of Mr A in Devon’.

NHS England has published a review looking at areas of concern following a total of five homicides in Devon in 2018 and 2019. Three involved Mr A (above). The other two led to separate mental health homicide reviews, involving Patient A and Mr S, which have already been published (below).

However, the primary focus of this review is on the learning from the three homicides committed by Mr A. The review includes a detailed examination of the critical events and decision-making points with reference to the events of February 2019.

An integrated action plan, setting out responses to the recommendations, has been developed by all agencies involved:

  • Devon Partnership NHS Trust
  • Devon County Council
  • Devon and Cornwall Police
  • G4S Health Services (UK) Ltd
  • NHS Devon

The action plan is held here by Torbay and Devon Safeguarding Adults Partnership, which co-commissioned the review.

Independent investigation into the care and treatment provided to Mr X by Devon Partnership NHS Trust (2013)

In 2013, NHS England (NHSE) assumed overarching responsibility for the commissioning of independent investigations into mental health homicides and serious incidents committed by patients being treated (or recently treated) for mental illness. Previously this responsibility had been held by the strategic health authorities.

The purpose of publishing the findings and learning from this investigation some years after the event is to ensure that NHS England and NHS Improvement openly and transparently shares all learning from commissioned NHS independent investigations.

It also serves to provide a progress report on how the learning has changed clinical practice and improved the quality of services to patients experiencing mental health problems in Devon.

The report’s findings and learning are available here.

An assurance report compiled by Devon Partnership NHS Trust, setting out service-improvements in response to the recommendations, is also available.

An independent investigation into the care and treatment of Patient A in Devon

NHS England has published a mental health homicide review into the care and treatment of Patient A, who was a service-user under the care of Devon Partnership NHS Trust. Patient A fatally stabbed a stranger outside a shopping centre in 2018.

Devon Partnership NHS Trust and NHS Devon have both published a joint action plan on their websites, in response to the report’s recommendations.

The action plans are available at:

An independent investigation into the care and treatment of Mr S in Devon

NHS England has published a summary mental health homicide review into the care and treatment of Mr S, who was a service-user under the care of Devon Partnership NHS Trust. Mr S fatally stabbed his father at his parents’ home in 2019.

Devon Partnership NHS Trust and NHS Devon have both published a joint action plan on their websites, in response to the report’s recommendations.

The action plans are available at: