Midlands
NHS Region85 health investigations in the Midlands region.
Independent investigation of the care and treatment of Mr N
Mental Health Investigation
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
Report PDF
Independent investigation report into the care and treatment of Mr N in Derbyshire
Mental Health Investigation
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
Report PDF
Action Plan
Independent investigation into the care and treatment of Mr S in the North Midlands
Mental Health Investigation
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
Report PDF
Independent investigation into the care and treatment of Ms Z in the North Midlands
Mental Health Investigation
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
Report PDF
Independent investigation: Adil Butt, Leicester (1996)
Mental Health Investigation
MH homicide. Ind Inq 1999 – failure to evaluate and assess properly
-1 recommendations
Report PDF
Independent investigation: Alan Clark, Barnsley (2000)
Mental Health Investigation
MH patient fatally and repeatedly stabs victim (affair). Ind Inq 2004
1 recommendation
Report PDF
Independent investigation: Alex Robinson, Lincoln (2014)
Mental Health Investigation
Mentally disordered man drowns grandson. Long MH history – Recently released from inpatient unit
16 recommendations
Report PDF
Independent investigation: Anthony Winship, Notts (1996)
Mental Health Investigation
MH Patient kills father after stabbing and repeatedly hitting him with hammer.. Ind Inq 1997
-1 recommendations
Report PDF
Independent investigation: Caroline Burningham, Welling-borough, Northants (1997)
Mental Health Investigation
Paranoid schizophrenic batters, sexually assaults and fatally strangles pregnant woman (stranger). Ind Inq 1999
-1 recommendations
Report PDF
Independent investigation: Christina Edkins, Birmingham (2013)
Mental Health Investigation
Paranoid schizophrenic fatally stabs schoolgirl. Many apparent failings in care
25 recommendations
Report PDF
Independent investigation: Debra Larn, Leicester (2006)
Mental Health Investigation
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: Edwin Whatsize, Glen Parva (2019)
Mental Health Investigation
Mentally disordered man repeatedly and fatally stabs grandfather. Diminished responsibility
3 recommendations
Report PDF
Independent investigation: Ellen FrithKatie BaxterZoe Pennick, NottinghamEast Midlands (2005)
Mental Health Investigation
D&A Patient fatally strangles victims (prob PD). Indep Inq due
-1 recommendations
Report PDF
Independent investigation: George Ackroyd, Hope, Derbyshire (1999)
Mental Health Investigation
Paranoid schizophrenic beheads father. Ind Inq 2002
-1 recommendations
Report PDF
Independent investigation: Geraldine Simpson, Birmingham (1997)
Mental Health Investigation
MH homicide of woman by throwing her from 12th floor flat. Ind Inq 2001
8 recommendations
Report PDF
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995)
Mental Health Investigation
Psychotic fatally stabbed mother and step brother, a month after release from psych unit. Ind Inq 1996
56 recommendations
Report PDF
Independent investigation: Halimah Ahmed, Derby (2007)
Mental Health Investigation
Psychiatric patient smothers girl then hangs himself. Ind Inq 2010. & Coroners report. Prev violence – Known risk – tried to section 3 times but no S/W
9 recommendations
Report PDF
Independent investigation: Jacob Billington, Birmingham (2020)
Mental Health Investigation
Paranoid schizophrenic fatally stabs student and seriously injures and stabs seven others. Life – Sec 45a order with minimum of 21 years
5 recommendations
Report PDF
Independent investigation: Jane Edwards, Hanwood, Shrewsbury (2010)
Mental Health Investigation
Psychotic man (who killed sister in 1985) fatally and stabs friend 50 times. Stopped Meds – Long MH history – released 2002
3 recommendations
Report PDF
Independent investigation: Janice Symons, Leicester (1995)
Mental Health Investigation
MH patient fatally stabs landlady. Ind Inq 1996
-1 recommendations
Report PDF
Independent investigation: Jill Louis Nevitt, Oswestry (2010)
Mental Health Investigation
Mentally ill man fatally and repeatedly stabs wife 28 times. MH history of depression and PTSD
1 recommendation
Report PDF
Independent investigation: Joanne Butler, East Shilton, Leics (2006)
Mental Health Investigation
Mentally ill man batters mentally ill neighbour and sets house on fire. Ind Inq (ref 9090) 2010
18 recommendations
Report PDF
Independent investigation: John Coxall, HMP Nottingham (2015)
Mental Health Investigation
Recent mental health patient fatally chokes vulnerable fellow prisoner. Previous inpatient at secure unit
1 recommendation
Report PDF
Independent investigation: John Dawson, Leics (1995)
Mental Health Investigation
MH homicide, kidnapping of stranger w firearm. Ind Inq 1997
-1 recommendations
Report PDF
Independent investigation: John McGrath, Stapleford, Nottingham (2009)
Mental Health Investigation
Schizophrenic man repeatedly and fatally stabs grandfather. Long MH history, family warnings, repeated missed opportunities. Judge criticised MH professionals
5 recommendations
Report PDF