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