Health Investigations

Independent health investigation reports and reviews commissioned by government or NHS England. Includes mental health homicide investigations, major maternity reviews, patient safety reviews, and other independent investigations into healthcare failures.

797
Investigations
5779
Recommendations
11
Regions

Investigations by Region

Key Findings

797 independent health investigations across 11 regions, producing 5,779 recommendations. 71% of investigations have extracted recommendations. 562 investigations have recommendations tracked.
Independent investigation: Anastasia Voykina, Streatham (2012)
London
Mentally ill man off meds fatally batters girlfriend with hockey stick. Violent history, Should have been seen daily by CMHT
15 recommendations Report PDF
Independent investigation: Andrew Else, Croydon (2014)
London
Paranoid schizophrenic fatally stabs stranger 200 times. Had previously stabbed teenager in head three weeks earlier
6 recommendations Report PDF
Independent investigation: Angela Titley, Private Psych hospital, Redhill, Surrey (2004)
South East
Psychotic MH patient fatally and repeatedly stabbed lover with Swiss Army Knife. Ind Inq 2009. May have missed meds
-1 recommendations Report PDF
Independent investigation: Anita Bawtree, Southampton (2011)
South East
Psychotic man fatally and repeatedly stabbed partner. Extensive Drug history. Recently released from MHA
28 recommendations Report PDF
Independent investigation: Anne Morris, Troon (2012)
Scotland
Mentally ill man kills mother and attacks father who survives. Patient of Sussex Partnership Trust in England
5 recommendations Report PDF
Independent investigation: Annette Sturt, Dover (2012)
South East
Paranoid schizophrenic fatally batters and strangles his mother. Heavy drug abuse
3 recommendations Report PDF
Independent investigation: Annie Garbutt, Mirfield (2007)
North East and Yorkshire
Mentally ill woman batters grandmother to death with garden spade. Ind inq. Verita, 2012
8 recommendations Report PDF
Independent investigation: Anthony Harrison, Andover (1998)
South East
Detained MH patient leaves hospital and fatally stabs man. Ind Inq 2001. Later hanged himself at Broadmoor
16 recommendations Report PDF
Independent investigation: Anthony Kellman, Brixton (1994)
London
Psychotic fatally shot one stranger and knifed another after mistakenly released from hospital. Ind Inq 2001 (!) – catalogue of errors – no risk ass, previous firearms use, Comm failures
9 recommendations Report PDF
Independent investigation: Anthony Kitely, Cardiff (2009)
Wales
Schizophrenic man attempted to kill his mother then fatally and repeatedly stabbed his friend. Long MH history, recently released by MHRT against advice
15 recommendations Report PDF
Independent investigation: Anthony Payne (80)Dick Carter (84)Roger Carter, Exeter (2019)
South West
Paranoid schizophrenic fatally batters elderly strangers with a hammer and spade. Previous inpatient, released twice by police, Dr said not detainable despite violence and talking of unicorns
12 recommendations Report PDF
Independent investigation: Anthony Radford, Pewley Down, Guildford (2005)
South East
Paranoid schizophrenic fatally and repaetedly batters man with log. MH History. (Ind Inq 2013, Verita)
-1 recommendations Report PDF
Independent investigation: Anthony Rigby, Blackburn (2002)
North West
Schizophrenic with history of violence fatally shot friend in the back of the head, three months after release from hosptal. Critical Ind Inq 2003
-1 recommendations Report PDF
Independent investigation: Anthony Wakeford, Effingham (2010)
South East
Mentally ill woman fatally stabs husband. Released at trial
8 recommendations Report PDF
Independent investigation: Anthony Winship, Notts (1996)
Midlands
MH Patient kills father after stabbing and repeatedly hitting him with hammer.. Ind Inq 1997
-1 recommendations Report PDF
Independent investigation: Antonio Tommaso, New Barnet (2014)
London
Paranoid schizophrenic repeatedly and fatally stabs friend & sets flat alight. Not taking Meds – Long MH history
9 recommendations Report PDF
Independent investigation: Arthur Lingard, Grimsby (2004)
North East and Yorkshire
Paranoid schizophrenic fatally batters stepfather. Critical Ind Inq (2004/487) 2008 -Few notes, inexperienced staff, warnings by family
3 recommendations Report PDF
Independent investigation: Ashleigh Ewing, Heaton, Newcastle (2006)
North East and Yorkshire
Paranoid schizophrenic fatally stabbed mental health worker 39 times with four knives.. Prev. attacked parents with hammer (GBH). Prev. arrested at Buck Pal threatening Queen. Refused medication, realised was danger to others.
-1 recommendations Report PDF
Independent investigation: Asiya Khatun, Newham (2000)
London
Mentally ill man fatally strangles his wife. Ind Inq 2002
-1 recommendations Report PDF
Independent investigation: Avril Hollens, Tonbridge, Kent (1999)
South East
MH patient fatally stabs girlfriend. Ind Inq 2003
-1 recommendations Report PDF
Independent investigation: Aysel Djevdet, Palmers Green (2009)
London
Psychotic depressive man fatally strangles wife
12 recommendations Report PDF
Independent investigation: Badi Saleem, Kings Cross (2011)
London
Paranoid schizophrenic fatally stabs man
10 recommendations Report PDF
Independent investigation: Barbara Coleman, Beds (1997)
East of England
Man with schizophrenia fatally stabbed a fellow patient. Ind Inq 1998
-1 recommendations Report PDF
Independent investigation: Beata Slomiana, Finchley (2010)
London
Paranoid schizophrenic kills girlfriend by putting plastic bag over her head. MH history – not taking meds
4 recommendations Report PDF
Independent investigation: Beatrice Hughes, Harrow (1997)
London
MH patient fatally punched kicked & stamped on pensioner during burglary. Ind Inq 2000
26 recommendations Report PDF