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: Colin Johnson, Sunderland (2004)
North East and Yorkshire
Paranoid schizophrenic kills former school friend with an axe.. long history of increasing MH problems. Family asked MH for help 83 times before incident.
-1 recommendations Report PDF
Independent investigation: Colin Ricketts, Laindon, Essex (2009)
East of England
Mentally ill man with paranoid delusions fatally stabs mother’s boyfriend
5 recommendations Report PDF
Independent investigation: Cooper Johnson-Hicks (9 mths), St Blazey (2016)
South West
Mentally disordered man fatally battered his young son and subsequently took his own life. Inquest found baby was unlawfully killed
2 recommendations Report PDF
Independent investigation: Daniel Coleman, Norfolk (1996)
East of England
MH Homicide. Ind Inq 2001 Armstrong
-1 recommendations Report PDF
Independent investigation: Daniel Quelch, Maidenhead, Berks (2007)
South East
Paranoid Schizophrenic breaks into house and fatally and repeatedly stab stranger in front of his children. Long MH history – sectioned 2001 – not taking meds
9 recommendations Report PDF
Independent investigation: Darren Edeson, Leeds (2011)
North East and Yorkshire
Had told psych nurses months before she wanted to kill. Had told psych nurses months before she wanted to kill
6 recommendations Report PDF
Independent investigation: Darren Flynn, HMP Swaleside (2015)
London
Two mentally disordered prisoners repeatedly & fatally stabs fellow prisoner
2 recommendations Report PDF
Independent investigation: Darren Lock, Newbury (2012)
South East
Mentally ill man fatally stabs man
9 recommendations Report PDF
Independent investigation: David Burrows, Ravensthorpe, Yorks (2005)
North East and Yorkshire
MH Homicide w knife whilst out on bail after conviction for assault. Ind Inq, (2005/3404) 2007. Previous hist of violence. Suicide in jail
6 recommendations Report PDF
Independent investigation: David Capseed, Liverpool (2019)
North West
Mentally disordered man with schizophrenia fatally battered acquaintance. Convicted of murder
6 recommendations Report PDF
Independent investigation: David Donnelly, Woolwich (2003)
London
Mentally ill man fatally stabs mentally ill neighbour. Long MH history, previous sec 37/41 but discharged & not recalled when unwell
-1 recommendations Report PDF
Independent investigation: David Fairburn, Barking (2004)
London
Homicide by mentally ill. Ind Inq 2010 NHS
4 recommendations Report PDF
Independent investigation: David Ford, Margate (2011)
South East
Man with schizophrenia fatally attacks fellow hostel resident
4 recommendations Report PDF
Independent investigation: David Huitson, Newcastle (2001)
North East and Yorkshire
Schizophrenic stabbed victim who had given evidence against him in another stabbing case.. Ind Inq 2004 – history of previous violence.
-1 recommendations Report PDF
Independent investigation: David Kemp, Great Yarmouth (2008)
London
MH patient absconds from secure unit and murders stranger. Previous serious violence
17 recommendations Report PDF
Independent investigation: David Limb, Wath (2004)
North East and Yorkshire
MH Homicide (+ alcohol). Ind Inq (2004/680) 2008
5 recommendations Report PDF
Independent investigation: David Philips, London (1998)
London
MH homicide. Ind Inq 2000
-1 recommendations Report PDF
Independent investigation: David Turnbull, Co Durham (1997)
North East and Yorkshire
MH homicide. Ind Inq 2000
-1 recommendations Report PDF
Independent investigation: Dawn Green, Newquay (2016)
South West
Depressed man fatally strangles wife then kills himself
9 recommendations Report PDF
Independent investigation: Dean Shorney, Bargoed (2006)
Wales
MH patient fatally and repeatedly stabs victim.. Critical Ind Inq 2008. Known high risk of violence.
5 recommendations Report PDF
Independent investigation: Debra Larn, Leicester (2006)
Midlands
MH patient fatally stabbed neighbour and wounded another (PD). Ind Inq 2007. Long MH history with violence. Predictable & preventable. Warnings. Poor team working.
-1 recommendations Report PDF
Independent investigation: Denise Eckersley, Leeds (1999)
North East and Yorkshire
MH battered wife to death. Ind Inq 2003
-1 recommendations Report PDF
Independent investigation: Denise Palmacci, Bedfordshire (1996)
East of England
Mentally ill man fatally stabs ex-girlfriend after release from Psychiatric hospital. Ind Inq 1997 Price
-1 recommendations Report PDF
Independent investigation: Denis Finnegan, Richmond Park (2004)
London
Psychotic fatally stabbed stranger whilst released from secure unit by Psych.. Ind Inq 2006. Errors made. Previous history of stabbing strangers
1 recommendation Report PDF
Independent investigation: Deraye Lewis, Bletchley (2004)
East of England
MH patient fatally punches toddler. Critical Inq. Verita 2010. (Case G) – PD and substance abuse
4 recommendations Report PDF