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.
William Mead – Root Cause Analysis Investigation Report
William Mead from Cornwall died on 14 December 2014, aged 12 months.
A coroner’s inquest into William’s death, held on 10 June 2015, identified missed opportunities for an earlier diagnosis and escalation which might have prevented the death of William.
A multi-agency investigation was undertaken into the circumstances of William’s death, led by NHS England and Kernow CCG. The findings of the investigation are contained within this Root Cause Analysis report, which makes recommendations for a number of organisations. Progress against those recommendations has also been published.
Independent investigation into the care and treatment of Mr MC and the homicide of Mr GN: May 2014
This is the report of the independent investigation into the care and treatment of Mr MC. South West Strategic Health Authority commissioned the care of Mr MC but NHS England took over the responsibility for commissioning these services as specialist commissioners following the reconfiguration of the NHS in 2013.
The trust response to the Niche Independent Inquiry into the care and treatment of Mr MC (a mental health service user) is available.
Lessons Learned Bulletin: Report into the homicide committed by a Recovery Team patient
These are the key lessons arising from an internal trust investigation into a mental health homicide in the South West, with five ‘key learning points’ distilled from 14 recommendations and summarised as a series of questions for individual staff, governance leads, board assurance and system learning.