Midlands

Paranoid schizophrenic fatally stabbed wife in front of children whilst on unsuper-vised release from MH unit. Critical Ind Inq 2004

Paranoid schizophrenic kills wife in ‘savage’ attack. Had previously served hospital order for seriously assaulting another partner

Psychotic man fatally and repeatedly stabs girlfriend. Heavy cannabis user. Tried to access help without success

Ex High Secure Mental Health Patient fatally punches man. Inq found he had been released too early from Rampton

Mentally ill man in stolen car fatally reverses over stranger, after assaulting a family claiming he was Jesus. Convicted Manslaughter by diminished responsibility

Psychotic MH patient stabs young boy (stranger) and father then beats pensioner to death (also a stranger). Ind Inq 2001 – prev hist of violence, left hospital day before, terrible failures, stopped meds.

Detained paranoid schizophrenic leaves hospital without permission and kills brother in law. Ind Inq 2005

The investigation was commissioned by NHS England following the fatal stabbings of three people in Nottingham in June 2023. Three others sustained serious injuries. The purpose of the investigation is to help the NHS and partners understand if there are lessons that could be learned that could prevent something similar happening in the future. The report published shares all the findings and recommendations for that purpose. NHS Nottingham and Nottinghamshire Integrated Care Board and Nottingham

This investigation relates to the care and treatment of an adult female (referred to as Ms P in the document) who was known to local mental health services prior to her conviction for homicide in 2023. The subsequent investigation, carried out by Niche consulting, identified four recommendations, which are set out as Critical Learning Points in theshared learning bulletin. These recommendations relate to Individual practice; Governance focussed learning; Board assurance; and System learning poin

Independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, commissioned by the Secretary of State for Health and Social Care in 2017. Led by Donna Ockenden (senior midwife). Final report published 30 March 2022. Reviewed 1,486 families over 20 years (2000–2019), finding repeated failures in care involving three maternal deaths and multiple baby deaths and brain injuries. Identified a culture of not listening to women, poor teamworking, and failure to learn from adverse events. Made 15 Immediate and Essential Actions (IEAs) applicable to all NHS trusts, and 64 Local Actions for Learning specific to the trust. Government accepted all national recommendations on publication and committed £127m to maternity services improvement.

The investigation resulted from the death of a woman and her male child in 2021 and was commissioned by NHS England once all related criminal proceedings had been concluded. 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.

This investigation relates to the care and treatment of Mr B during the period between October 2020 and 11 July 2023 when a homicide took place. At the time of the incident the service user was receiving care from a Community Mental Health Team. In October 2023, the NHSE Independent Investigation Review Group commissioned an investigation.The following documentrepresents a learning summary of this independent review, carried out by Psychological Approaches CIC, and the Trust has provided NHS Eng

ThisLearning Summarywas commissioned by NHS England to independently assess the quality of the NHS care and treatment provided to M against best practice, national guidance, and Trust policy, and to identify opportunities for learning that may be applicable on a local, regional or national basis. On 24thMarch 2020 M murdered a woman he was working for. He was sentenced to a hospital order and detained under the Mental Health Act.

The investigation was prompted by an incident in Birmingham in 2020 that resulted in: 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.

The investigation resulted from the death of a 87 year-old man in 2019 and was commissioned by NHS England once all related criminal proceedings had been concluded. 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.

The investigation resulted from the death of a 59 year-old woman in 2018 and was commissioned by NHS England once all related criminal proceedings had been concluded. 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.The way that mental health services are delivered in Herefordshire has changed since the incident in 2018 (please seeherefor more details). That’s why t

NHS England has published anindependent investigation reportinto the treatment and care of ‘Mark’, who killed his step-grandfather after moving from Nottinghamshire to Dorset in 2018.

P was charged with the murder of Christina in 2013. The independent External Quality Assurance Review was commissioned by NHS England to review progress against the recommendations and actions identified as part of the independent investigation which was published in June 2017. All future updates on progress will be published by the individual organisations concerned.

Patient P was convicted of manslaughter with diminished responsibility of Christina. He had previously been in contact with mental health services and prison mental health services in the West Midlands.

NHS England Midlands Region, commissioned Niche Health and Social Care Consulting Ltd to carry out an independent investigation into the care and treatment of mental health service user SV following a domestic homicide in 2017. The main purpose of an independent investigation is to ensure that mental health care-related homicides are investigated in such a way that lessons can be learned effectively to prevent recurrence. The investigation process may also identify areas where improvements to se

The investigation was prompted by the death of a 34 year-old man in 2017 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the investigation is to help the NHS and partners understand if there are lessons that could be learned that could prevent something similar happening in the future.

The investigation was prompted by the death of a 37 year-old woman in 2017 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the investigation has been to help the NHS and partners understand if lessons can be learned that could prevent something similar happening in the future.

A Pathway Review of care for people with severe mental ill health who present a level of risk to others in Black Country Healthcare NHS Foundation was designed to support learning and development following an incident that occurred in 2016. The work was commissioned by NHS England and led by our independent clinical team.The main reportcontains information about the methodology, the background, findings and agreed recommendations.

Patient H was convicted of convicted of manslaughter with diminished responsibility of Mrs H. At the time of the death patient H was under the care of Birmingham and Solihull Mental Health NHS Foundation Trust.

Patient X was convicted of convicted of manslaughter with diminished responsibility of Ms Y. At the time of the death patient X was under the care of South Staffordshire Shropshire Healthcare NHS Foundation Trust.