East of England
NHS Region88 health investigations in the East of England region.
Independent investigation: Ryan Walsh, Cheshunt (2008)
Mental Health Investigation
Mental health patient fatally stabs boyfriend. MH history w violence – inquiry found many failings in care. Ind inq. 2013 Iodem
-1 recommendations
Report PDF
Independent investigation: Samantha Ho, St Neots (2015)
Mental Health Investigation
Paranoid schizophrenic beheads wife and stabs family dog. Long MH history
7 recommendations
Report PDF
Independent investigation: Sandra Crawford, St Albans (2010)
Mental Health Investigation
Psychotic man fatally and repeatedly stabs neighbour. Family took him to hospital day before but released.
18 recommendations
Report PDF
Independent investigation: Sean Hand, Basildon (2003)
Mental Health Investigation
MH Homicide by stabbing. Ind Inq 2008. Released despite homicidal thoughts, poor records
7 recommendations
Report PDF
Independent investigation: Steven Janczuk, Arlesey, Beds (2006)
Mental Health Investigation
Mentally ill woman fatally stabs husband. MH History
9 recommendations
Report PDF
Independent investigation: Suzanne Brown, Braintree (2017)
Mental Health Investigation
Paranoid schizophrenic repeatedly and fatally stabbed partner after meds stopped. Family warned repeatedly about deterioration
7 recommendations
Report PDF
Independent investigation: Terry Ojuederie, Peterborough (2015)
Mental Health Investigation
Psychotic man beats cell mate to death. Substance abuse history
11 recommendations
Report PDF
Independent investigation: Thomas Baird, Hemel Hempstead (2013)
Mental Health Investigation
Recent MH patient batters and stabs ex-girlfiend’s father. Previous history of violent assaults
-1 recommendations
Report PDF
Independent investigation: Tracy Anstice, Flitwick (2011)
Mental Health Investigation
Mentally ill man fatally stabs ex-wife
8 recommendations
Report PDF
Independent investigation: Valerie Jozunas, Wimbish, Saffron Walden (2020)
Mental Health Investigation
Mentally ill man repeatedly and fatally stabbed mother. Later died in prison.
12 recommendations
Report PDF
Independent investigation: Vera Croghan, Norwich (2020)
Mental Health Investigation
Man with schizophrenia starts fatal fire at his grandmother’s house. Recent inpatient – Diminished responsibility Sec 37/41
4 recommendations
Report PDF
An independent investigation into the care and treatment of Sam in Essex
NHS England East of England Region and Midlands Region, commissioned Niche Health and Social Care Consulting Ltd (Niche) to carry out an independent investigation into the care and treatment of mental health service user, Sam. Documents:
Report PDF
Action Plan
An independent investigation into the care and treatment of Colin – April 2025
Mental Health Investigation
This independent review commissioned by NHS England looks at the care and treatment that Colin received between January 2021 and his subsequent death in September 2021. The review included the nature and extent of involvement of all agencies, private and NHS, that Colin had contact with, dating back to his first contact with services in relation to his symptoms of confusion. Documents
17 recommendations
Report PDF
Action Plan
Pathway Review: Central and North-West London NHS Foundation Trust Mental Health Services, Milton Keynes – October 2024
Pathway Review
A pathway review was commissioned by NHS England to understand the service changes made after a serious incident involving a death several years ago. The perpetrator was a young man who had been admitted informally via Street Triage with psychotic symptoms, but he left the ward without permission and police subsequently established that a young woman had been killed. Central and North-West London NHS Foundation Trust is responsible for a number of actions identified within the teview and hold a
4 recommendations
Report PDF
Independent review of care by Norfolk and Suffolk Mental Health NHS Foundation Trust – August 2024
Mental Health Investigation
This independent review report has been commissioned by NHS England relating to the care provided by Norfolk and Suffolk Mental Health NHS Foundation Trust for an individual who was responsible for the death of their grandmother. This report aims to strengthen local services in the context of the evidence and relevant information about the incident. The report supports learning and informs the NHS and the public on future service provision.
4 recommendations
Report PDF
Key findings and action plan – Final report: Norfolk and Suffolk NHS Foundation Trust: Early intervention in psychosis team pathway …
Pathway Review
This reportwas commissioned by the trust and made twelve recommendations to improve the care and treatment of service users, and three recommendations to improve practice following a serious incident. The investigation was prompted by the death of an 84-year-old gentleman who had been walking his dog in a remote wooded area in Norfolk by a 23-year old man. At the time of the homicide the young man was not under the care of mental health services, but he had had three previous episodes of care pr
9 recommendations
Report PDF
Independent investigation into the care and treatment received by Mr B
Mental Health Investigation
The aim of this report is to help improve the delivery of care for people who are at risk of self-harm. Mr B was a 50-year-old man who had been living with secondary progressive multiple sclerosis (MS) for over 20 years and was living in a care home. On 27 May 2023, Mr B left the assessment unit of Brook Meadows House (BMH) where he had been living since 10 June 2022, and travelled to Kent, where he ended his life. Documents
7 recommendations
Report PDF
Action Plan
Independent investigation into the care and treatment of Mr M – August 2021
Mental Health Investigation
This investigation was commissioned by NHS England and was conducted in partnership with the Domestic Homicide Review which was commissioned by Southend, Essex and Thurrock Domestic Abuse Board. The investigation was prompted by the death of a woman in Essex in 2020. The purpose of the investigation was to help the NHS and partners understand if there are lessons that could be learned that could prevent something similar happening in the future.
12 recommendations
Report PDF
An independent investigation into the care and treatment of Mr Z – July 2021
Mental Health Investigation
The findings of an independent investigation into the circumstances surrounding the care and treatment of Mr Z are published on this webpage: Essex Partnership University Trust and NHS Thurrock ICS, which are cited in the report’s recommendations, have also published an action planan action planin response to the findings.
5 recommendations
Report PDF
An independent investigation into the NHS care and treatment of Mother in Essex – December 2020
Mental Health Investigation
The findings of an independent investigation into the circumstances surrounding the care and treatment of Mother in Essex are published on this webpage. Mother had been under the care of secondary mental health services since March 2017. Following the homicide of Child R by his Mother in July 2018, NHS England commissioned an independent investigation into the care and treatment of mental health service user, Mother. An independent investigation into Mother and a related serious case review int
3 recommendations
Report PDF
An independent investigation into the care and treatment of a mental health service user James in Essex – November 2020
Mental Health Investigation
The findings of an independent investigation into the circumstances surrounding the care and treatment of James are published on this webpage. James killed his long-term girlfriend in December 2017. He had been a patient of North Essex Partnership Trust (NEPT), now Essex Partnership University Trust (EPUT) since 2000. A joint Independent Investigation and Domestic Homicide Review has taken place and both reports are available below: Essex Partnership University Trust, which is cited in the indep
7 recommendations
Report PDF
An independent investigation into the care and treatment of a mental health services user ‘Mr P’ in Essex – June …
Mental Health Investigation
Findings are published today of an independent investigation into the circumstances surrounding the care and treatment of Mr P, a mental health service user in Essex . Sincerest sympathies are offered to all the people who have been affected by this tragic event. Mr P killed Mrs H and Mr F at his mother’s address in Essex on 22 July 2015. Mr P was convicted of the murder of the two victims, who were his mother and her friend, and received a life sentence in May 2016. NHS England – East of Englan
5 recommendations
Report PDF
An independent investigation into the care and treatment of Mr Q – 2020
Mental Health Investigation
The Learning Document from the independent investigation into the circumstances surrounding the care and treatment of Mr Q are published on this webpage:
Report PDF
Independent Review into the NHS Care and Treatment Provided to Mr O – January 2018
Mental Health Investigation
Patient Mr O killed Ms M and was convicted of her murder. He was in contact with mental health services delivered by Hertfordshire Partnership University NHS Foundation Trust and was previously a patient of Avon and Wiltshire Mental Health Partnership NHS Trust. This independent review was undertaken alongside aMulti Agency Partnership Reviewinto the death of Ms M in December 2015 which was commissioned by the Hertfordshire Adult Safeguarding Board. In 2019, NHS England commissioned an assurance
4 recommendations
Report PDF
Independent investigation into the care and treatment of patient M – March 2017
Mental Health Investigation
Patient M killed his cellmate in HMP Peterborough and was subsequently convicted of manslaughter on the grounds of diminished responsibility. The investigation was conducted jointly with the Prison and Probation Ombudsman (PPO) investigation into the death in custody of M’s cellmate.
11 recommendations
Report PDF