South West Region
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.
Independent review of the care and treatment received by JW prior to an incident of homicide in December 2020
Publication date 7 November 2023.
NHS England has published an independent investigation report into the care and treatment of ‘JW’, who killed an employee at the accommodation where he was staying in December 2020.
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.
Lessons Learned Bulletin: An independent investigation into the care and treatment of Adult 1
Published December 2024
An overview of the findings from an independent investigation into the care and treatment given to Adult 1, a mental health service user, who fatally attacked a family member, Adult 2, in 2021. Agencies and teams who might benefit from this bulletin include adult community and inpatient mental health services, safeguarding teams, adult social care services, ambulance services and GP/primary care teams.
Click here for the full bulletin
Lessons Learned Bulletin: An independent investigation into the care and treatment of a patient of mental health services prior to a homicide
Published December 2024
An overview of the findings from an independent investigation into the care and treatment given to a mental health service user, who fatally attacked a family member in 2021. Agencies and teams who might benefit from this bulletin include adult community mental health services, prison mental health services and safeguarding teams.