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: Carol Houghton, Birkenhead (1998)
North West
Schizophrenic fatally battered girlfriend around face and head.. Ind Inq 2001, Ceased meds, previously sectioned after stabbing
-1 recommendations Report PDF
Independent investigation: Caroline Burningham, Welling-borough, Northants (1997)
Midlands
Paranoid schizophrenic batters, sexually assaults and fatally strangles pregnant woman (stranger). Ind Inq 1999
-1 recommendations Report PDF
Independent investigation: Caroline Coates, Dalston (1997)
London
Mentally ill man repeatedly and fatally stabs woman. Ind Inq 2000
-1 recommendations Report PDF
Independent investigation: Caroline Evans, Llangadog, Camarthen (2003)
Wales
MH patient fatally shot victim then shot himself. Ind Inq 2005 – Previously sectioned for shotgun threat. Public protection not considered
37 recommendations Report PDF
Independent investigation: Caroline WillsAshley Wills, Cramlington, North-umberland (2000)
North East and Yorkshire
Paranoid Schizophrenic kills sister and her son in frenzied attack.. Ind Inq 2002
12 recommendations Report PDF
Independent investigation: Carol Trethewey (Mrs S), St Austell, Cornwall (2000)
South West
Depressive repeatedly and fatally stabbed wife. Ind Inq 2003, failings in care,got 3 yrs probation
4 recommendations Report PDF
Independent investigation: Carol Wetherley, Needham (2010)
East of England
Paranoid Schizophrenic slits mother’s throat claiming Jesus made him do it.. MH History
2 recommendations Report PDF
Independent investigation: Casey Kearney, Doncaster (2012)
North East and Yorkshire
Recent MH patient fatally stabs teenager. Drug History. Long MH history, asked to be sectioned, warned not to carry knives
21 recommendations Report PDF
Independent investigation: Catherine Hampshire, Gant’s Hill (1994)
London
MH patient fatally stabs wife wife 300 times in head and neck – failed to take meds. Ind Inq 1996
-1 recommendations Report PDF
Independent investigation: Catherine Ogram, Aldershot (2002)
South East
Schizophrenic fatally punched and stabbed his girlfriend. Long history of MI – clear warning signs beforehand
14 recommendations Report PDF
Independent investigation: Cerys Yemm, Argoed (2014)
Wales
Mentally ill man fatally batters young woman. Recently released from prison with lack of aftercare
10 recommendations Report PDF
Independent investigation: Charles Taylor, Poole (2018)
South West
Mentally disordered man fatally battered his step-grandfather
3 recommendations Report PDF
Independent investigation: Chloe Fahey, Manchester (2003)
North West
Fatally stabbed daughter 52 times – attacked partner day before. Ind Inq 2010 – recently released MH patient – family and school concerns ignored
48 recommendations Report PDF
Independent investigation: Chloe Sutherland (8 mnths), Edinburgh (2015)
Scotland
Post-natally depressed mother fatally smothers daughter. Unable to access care as baby ‘too old’
13 recommendations Report PDF
Independent investigation: Chris Poole, Eastbourne (2012)
South East
Mentally ill man fatally punches and kicks man
6 recommendations Report PDF
Independent investigation: Chris Stones, Worthing (2005)
South East
Paranoid Schizophrenic stabs father of two. Long MH history
-1 recommendations Report PDF
Independent investigation: Christina Edkins, Birmingham (2013)
Midlands
Paranoid schizophrenic fatally stabs schoolgirl. Many apparent failings in care
25 recommendations Report PDF
Independent investigation: Christoph Duclos, Mile End Tube (2002)
London
Psychotic pushed stranger into oncoming train. Ind Inq 2006. Personality disorder and dual diagnosis
5 recommendations Report PDF
Independent investigation: Christopher Edwards, Chelmsford prison (1994)
East of England
Schizophrenic homicide. Ind Inq 1998, Coonan (European Court HR case)
-1 recommendations Report PDF
Independent investigation: Christopher Ritchie, Durham (2020)
North East and Yorkshire
Paranoid schizophrenic fatally stabbed acquaintance. Diminished responsibility – indefinite hospital order
6 recommendations Report PDF
Independent investigation: Claire Wilson (& unborn baby), Grimsby (2009)
North East and Yorkshire
Mentally ill man fatally stabs pregnant stranger killing her and her unborn daughter. Prev. 3 inpatient stays after threatening to kill someone with knives
17 recommendations Report PDF
Independent investigation: Clara Joughlin, Isle of Man (1995)
Northern Ireland
MH patient attacks two daughters, killing younger one. Ind Inq 1997. Long MH history
-1 recommendations Report PDF
Independent investigation: Colin Anderson, Newcastle (2006)
North East and Yorkshire
Recently released mentally ill man (with depressive LD accomplice) batters man and throws him off tower block.. Recently released after psychotic episode. Ind Inq due.
20 recommendations Report PDF
Independent investigation: Colin Beynon, Bristol (1995)
South West
Schizophrenic batters father to death with hammer on home visit. Ind Inq 1997 found “string of errors”
-1 recommendations Report PDF
Independent investigation: Colin Greenway, Thamesmead (2013)
London
Psychotic man fatally batters and cuts throat of disabled man. Previous violence, not taking meds, long MH history
-1 recommendations Report PDF