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: Ben Cargill (Mr D), Chesham, Bucks (2004)
South East
Mentally ill man repeatedly and fatally stabbed former flatmate. Ind Inq 2006
14 recommendations Report PDF
Independent investigation: Benjamin Durao, Brixton (2004)
London
Mentally ill teenager fatally stabs man. MH history.(Ind Inq. 2010 NHS)
4 recommendations Report PDF
Independent investigation: Bernadette FoxSarah Fox, Bootle (2015)
North West
Paranoid Schizophrenic strangles mother and fatally stabs sister. Off meds and abusing substances
13 recommendations Report PDF
Independent investigation: Bernard Clark, Barnsley, Yorkshire
North East and Yorkshire
Paranoid Schizophrenic stabbed father.. Ind Inq (2004/3403) 2008. Previously sectioned for attempted murder. Ceased meds before killing
22 recommendations Report PDF
Independent investigation: Bertha Martin, Cleadon (2008)
North East and Yorkshire
Mentally ill woman fatally batters mother. Previously sectioned & violent, released without aftercare. Ind Inq 2014 NHS North
29 recommendations Report PDF
Independent investigation: Bethany Rae Fields, Huddersfield (2019)
North East and Yorkshire
Mentally disordered and coercive man fatally and repeatedly stabs friend. MH staff warned three times previously of his threats to kill
4 recommendations Report PDF
Independent investigation: Bianca ‘Kay’ Shepherd, Uxbridge (2015)
London
Paranoid schizophrenic fatally stabs housemate. Previous history of aggression and violence
4 recommendations Report PDF
Independent investigation: Boris Reavey, Bedford (2008)
East of England
Paranoid schizophrenic fatally stabs stranger three days after release from psych. hospital. long MH history had been inpatient 15 times
-1 recommendations Report PDF
Independent investigation: Brenda Horrod, Hickling, Norfolk (1995)
East of England
MH patient fatally batters, stabs and smothers wife day after leaving hospital. Ind Inq 1998, Armstrong
-1 recommendations Report PDF
Independent investigation: Brenda Lindley, Northfleet (2007)
South East
Mentally ill man fatally batters wife then kills himself
6 recommendations Report PDF
Independent investigation: Brian Cherry, Walthamstow (2004)
London
Mentally ill man killed victim, cut off both arms & one leg, fried brains. Later murdered Loudwell (qv) in Broadmoor. Ind Inq 2009. Had previously been released from secure hospital as no threat.
-1 recommendations Report PDF
Independent investigation: Brian Dodd, Prestatyn (2003)
Wales
Paranoid schizophrenic fatally and repeatedly (28 times) stabbed a stranger. V critical indep inq 2004, previously slashed strangers throat 1996. released 2000. Prev danger to others noted. Had stopped meds
22 recommendations Report PDF
Independent investigation: Brian Haynes, Peterborough (2008)
East of England
Mentally disordered man involved in fatal attack on inmate. Inq found poor care and missed opportunities
-1 recommendations Report PDF
Independent investigation: Brian Kemp, Sidmouth (2013)
South West
Psychotic man fatally stabs stranger. Deteriorating for months before
2 recommendations Report PDF
Independent investigation: Brian Marsh, Swindon (2007)
South West
Mentally ill man in frenzied fatal attack on stepfather, and attacks mother. Many failings – Preventable homicide
23 recommendations Report PDF
Independent investigation: Bridget MaclennanElizabeth Valad, Camden
London
Psychiatric patient killed and cut up bodies. Ind Inq 2005 Lengthy psych history, ind inq claimed ‘clinically normal’ at time of killings
-1 recommendations Report PDF
Independent investigation: Bryan Bennett, Newham (1994)
London
MH patient fatally stabbed victim more than 80 times. Ind Inq 1995 – previous violence
3 recommendations Report PDF
Independent investigation: Camille Remy (pregnant), Hackney (2006)
London
Paranoid Schizophrenic fatally and repeatedly stabbed stranger student.. Ind Inq. Released from hospital against medical advice. History of violence with blades
24 recommendations Report PDF
Independent investigation: Carla Thompson, Merton (1998)
London
MH homicide – prolonged and violent assault,. Ind Inq 2000
-1 recommendations Report PDF
Independent investigation: Carl Everson, Barking (2010)
London
Mental health patient batters man and fatally stabs him. Inq found many failings in care – had killed before. Ind inq, Wynchcombe, 2013
9 recommendations Report PDF
Independent investigation: Carl James, Swindon (2007)
South West
Schizophrenic fatally stabbed friend 6 times. Prev. threatened violence. Mother warned MH services
4 recommendations Report PDF
Independent investigation: Carl Scott, Winchester
South East
Schizophrenic man fatally battered and stabbed man
11 recommendations Report PDF
Independent investigation: Carmel Charles, Catford (2011)
London
Mentally ill man fatally stabs woman. MH history
6 recommendations Report PDF
Independent investigation: Carmelita Tulloch, Vauxhall, London (2006)
London
Paranoid schizophrenic stabbed a stranger seven times
23 recommendations Report PDF
Independent investigation: Carole Dyson, Adlington (2014)
North West
Mentally disordered man fatally strangles wife
11 recommendations Report PDF