Mental Health Investigation
CategoryIndependent investigations into the care and treatment of mental health service users
Independent investigation into NHS mental health care of ‘X’
East of England
This Mental Health Homicide Review (MHHR) has been commissioned by NHS England regarding person ‘X’ who had been in contact with mental health services. X died from a fall from a height. X’s wife, Y, was subsequently found to have died due to strangulation. The Major Crime Team concluded that the deaths were due to murder and suicide. Documents Independent Assurance Review – Assurance of the investigation report and action plan relating to the care and treatment received by PS prior to homicide
4 recommendations
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Action Plan
Independent investigation into the care and treatment of Mr X and Mr Y
London
This is the independent investigation report into the care and treatment provided to Mr X and Mr Y.
11 recommendations
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Action Plan
Independent investigation of the care and treatment of Mr N
Midlands
This document provides an overview of key findings from an independent investigation into the NHS care of a young man (Mr N) who killed a close relative. The subsequent investigation, carried out by Psychological Approaches, identified six recommendations, which are set out in thepublished learning summary. Key findings of the review relate to information sharing and joint working; risk assessment; and care planning. Agencies and teams who might benefit from this bulletin
6 recommendations
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Independent investigation report into the care and treatment of Mr N in Derbyshire
Midlands
Mr N was released from prison whilst detainable, but no suitable bed could be found. Mr N approached a policeman saying he was hearing voices telling him to kill people. The policeman took him to the local Emergency Department where he spent two days waiting for a bed. He was transferred to an Enhanced Care Ward and placed in seclusion, before his transfer into higher secure services after a couple of weeks. This was a near miss and investigated due to the potential for learning across system
10 recommendations
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Action Plan
Independent investigation into the care and treatment of Mr S in the North Midlands
Midlands
Patient Mr S killed victim 1 and victim 2 and then committed suicide. He had been in contact with mental health services delivered by Derbyshire Healthcare NHS Foundation Trust.
3 recommendations
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Independent investigation into the care and treatment of Ms Z in the North Midlands
Midlands
Patient Ms Z was convicted of manslaughter with diminished responsibility of the victim. She had previously been in contact with mental health services delivered by Derbyshire Healthcare NHS Foundation Trust.
18 recommendations
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Root Cause Analysis Investigation Report into the Death ofDr Julien Warshafsky
South East
NHS England has published aRoot Cause Analysis Investigation Report into the Death of Dr Julien Warshafsky. The focus of this case review is to explore opportunities for collective learning and identify actions that could be either considered or taken to minimise the risk of recurrence.
1 recommendation
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Independent investigation: Abdullah Jama, Blackheath (2009)
North East and Yorkshire
Paranoid Schizophrenic fatally batters with an axe after leaving Sheffield Psych Unit and Greenwich hospital. Long MH history, not taking meds
12 recommendations
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Independent investigation: Abida Bi, Bradford (2010)
North East and Yorkshire
Paranoid schizophrenic beats wife to death with crowbar. Long MH history. Prev. threats to kill wife. (Ind Inq 2012 Dineen)
3 recommendations
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Independent investigation: Adam Nightingale, Rochdale (2015)
North West
Mentally ill man with history of violence fatally punches stranger. Investigation finds death was preventable
10 recommendations
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Independent investigation: Adel Makar, Westcliff on Sea (2006)
East of England
MH patient fatally stabs father then hangs himself
25 recommendations
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Independent investigation: Adil Butt, Leicester (1996)
Midlands
MH homicide. Ind Inq 1999 – failure to evaluate and assess properly
-1 recommendations
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Independent investigation: Adrian Pawson, Wakefield (1998)
North East and Yorkshire
Paranoid Schizophrenic hospital patient with collection of knives fatally and repeatedly stabbed another patient. Ind Inq 2001, wrong risk assessment, avoidable
-1 recommendations
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Independent investigation: Aiyse Sullivan, Dorset (1997)
South West
Mentally ill man killed girlfriend (PD). Ind Inq 2000
-1 recommendations
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Independent investigation: Alan Clark, Barnsley (2000)
Midlands
MH patient fatally and repeatedly stabs victim (affair). Ind Inq 2004
1 recommendation
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Independent investigation: Alan Clarke, Salisbury (2008)
South West
Mentally ill man fatally stabs friend. Dem Resp – hospital order MSU
-1 recommendations
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Independent investigation: Alan Creasey, Lancing (2017)
South East
Mentally disordered man fatally batters and stamps on man. Convicted of Murder
6 recommendations
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Independent investigation: Alan Geddes, Aberdeen (2019)
Scotland
Paranoid and deluded former patient repeatedly and fatally stabs stranger on release from prison. History of violence, drug abuse, & psychosis – convicted of murder
11 recommendations
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Independent investigation: Alan Riddock, Bristol (2008)
South West
Mental health patient beats man to death. MH history.Ind inq 2013 HASCAS
-1 recommendations
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Independent investigation: Alan ScottStella Scott, Allerton, Liverpool (2008)
North West
Schizophrenic repeatedly and fatally stabbed parents. Previous inpatient
3 recommendations
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Independent investigation: Albert Wright, Hainault (2011)
East of England
Mentally ill man fatally stabs elderly relative
8 recommendations
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Independent investigation: Alex Robinson, Lincoln (2014)
Midlands
Mentally disordered man drowns grandson. Long MH history – Recently released from inpatient unit
16 recommendations
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Independent investigation: Alexander Cusworth, HMP Dartmoor (2015)
South West
Mentally disordered prisoner with history of violence fatally stabs fellow prisoner
2 recommendations
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Independent investigation: Alison Gable, Theale (2003)
South East
Sectioned MH patient on day release kills girlfriend. Ind Rev 2004 – originally unpubl. Not in public interest
-1 recommendations
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Independent investigation: Alison McKenzie, Middlesbrough (2019)
North East and Yorkshire
Paranoid schizophrenic fatally stabs mother. Off meds – long history of serious mental illness
6 recommendations
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