Somerset

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.

An independent investigation into the care and treatment of Mr D

NHS England has published an independent investigation report into the care and treatment of Mr D, a newly-referred patient of mental health services in Somerset, who killed his neighbour in 2020.

An action plan in response to the report’s recommendations has been published by Somerset NHS Foundation Trust.

NHS England has also published a shared learning bulletin to distil the findings and lessons from the main investigation report.

An independent investigation into the care and treatment of a mental health service user Mr K in Somerset

NHS England has published an independent investigation report into the care and treatment of Mr K, a patient of mental health services in Somerset, who killed another man in Honiton in June 2017.

An action plan in response to the report’s recommendations has been published by Somerset Clinical Commissioning Group.

NHS England subsequently published a quality assurance review to assess progress on the recommendations.

Assurance report – Somerset Partnership NHS Foundation Trust

NHS England has published an assurance report following a homicide/suicide in 2015 that involved a patient under the care of mental health services in Somerset. The report looks at the investigation by Somerset Partnership NHS Foundation Trust, its subsequent action plan and the embedding of learning. It sets out recommendations both for the trust and for Somerset Clinical Commissioning Group (CCG).

The action plans arising from the assurance report are available here:

An independent investigation into the care and treatment of Mr S: August 2016

This is the report of the independent investigation into the care and treatment of mental health service user Mr S. At the time of the homicide, he was receiving services from Somerset Partnership NHS Foundation Trust.

Somerset Partnership NHS Foundation Trust have published the associated action plan.

This is the independent assurance report on actions following publication of the original review.

An independent inquiry into the care and treatment of Mr S: September 2014

This is the report of the independent investigation into the care and treatment of Mr S. At the time of the homicide (2011) Mr S was receiving care and treatment from Somerset Partnership NHS Foundation Trust.

This is the independent assurance report on actions following publication of the original review.