South West
NHS Region67 health investigations in the South West region.
Independent investigation: Aiyse Sullivan, Dorset (1997)
Mental Health Investigation
Mentally ill man killed girlfriend (PD). Ind Inq 2000
-1 recommendations
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Independent investigation: Alan Clarke, Salisbury (2008)
Mental Health Investigation
Mentally ill man fatally stabs friend. Dem Resp – hospital order MSU
-1 recommendations
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Independent investigation: Alan Riddock, Bristol (2008)
Mental Health Investigation
Mental health patient beats man to death. MH history.Ind inq 2013 HASCAS
-1 recommendations
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Independent investigation: Alexander Cusworth, HMP Dartmoor (2015)
Mental Health Investigation
Mentally disordered prisoner with history of violence fatally stabs fellow prisoner
2 recommendations
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Independent investigation: Alison Stevenson, Helston (2021)
Mental Health Investigation
Mentally disordered man repeatedly and fatally stabbed his grandmother. Convicted of Murder – Life – minimum 18 years
5 recommendations
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Independent investigation: Anthony Payne (80)Dick Carter (84)Roger Carter, Exeter (2019)
Mental Health Investigation
Paranoid schizophrenic fatally batters elderly strangers with a hammer and spade. Previous inpatient, released twice by police, Dr said not detainable despite violence and talking of unicorns
12 recommendations
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Independent investigation: Brian Kemp, Sidmouth (2013)
Mental Health Investigation
Psychotic man fatally stabs stranger. Deteriorating for months before
2 recommendations
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Independent investigation: Brian Marsh, Swindon (2007)
Mental Health Investigation
Mentally ill man in frenzied fatal attack on stepfather, and attacks mother. Many failings – Preventable homicide
23 recommendations
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Independent investigation: Carl James, Swindon (2007)
Mental Health Investigation
Schizophrenic fatally stabbed friend 6 times. Prev. threatened violence. Mother warned MH services
4 recommendations
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Independent investigation: Carol Trethewey (Mrs S), St Austell, Cornwall (2000)
Mental Health Investigation
Depressive repeatedly and fatally stabbed wife. Ind Inq 2003, failings in care,got 3 yrs probation
4 recommendations
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Independent investigation: Charles Taylor, Poole (2018)
Mental Health Investigation
Mentally disordered man fatally battered his step-grandfather
3 recommendations
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Independent investigation: Colin Beynon, Bristol (1995)
Mental Health Investigation
Schizophrenic batters father to death with hammer on home visit. Ind Inq 1997 found “string of errors”
-1 recommendations
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Independent investigation: Cooper Johnson-Hicks (9 mths), St Blazey (2016)
Mental Health Investigation
Mentally disordered man fatally battered his young son and subsequently took his own life. Inquest found baby was unlawfully killed
2 recommendations
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Independent investigation: Dawn Green, Newquay (2016)
Mental Health Investigation
Depressed man fatally strangles wife then kills himself
9 recommendations
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Independent investigation: Donna Smart, Shepton Mallet (2000)
Mental Health Investigation
MH homicide of wife (alc). Ind Inq 2001
-1 recommendations
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Independent investigation: Dorothy Shepherd, Winchcombe (2010)
Mental Health Investigation
Paranoid Schizophrenic fatally stabs grandmother. History of prev. violence. V many failings in care
26 recommendations
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Independent investigation: Earl Swaby, Bristol (2010)
Mental Health Investigation
Mental Health Patient convicted of manslaughter after fatal stabbing. MH history
-1 recommendations
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Independent investigation: Gary Miller, Plymouth (2016)
Mental Health Investigation
Mentally ill man fatally batters friend around the head
9 recommendations
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Independent investigation: Georgina Robinson, Torbay (1993)
Mental Health Investigation
Paranoid schizophrenic fatally stabbed occ. therapist in acute psych ward. Ind Inq 1995 MH failures, ‘entirely predictable’ previous assaults
-1 recommendations
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Independent investigation: Gino Nelmes, Bristol (2012)
Mental Health Investigation
Paranoid schizophrenic fatally stabs friend 18 times with samurai sword. Prev. history of violence; released from secure unit days before assault
13 recommendations
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Independent investigation: John Witts, Cinderford (1995)
Mental Health Investigation
Mentally ill man fatally stabs brother. Ind Inq 1997
-1 recommendations
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Independent investigation: Joseph Osmond, Salisbury (1997)
Mental Health Investigation
Mentally ill man fatally and repeatedly stabbed landlord. Ind Inq 1999. previously sectioned, then released before killing
-1 recommendations
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Independent investigation: Joyce Lovell, Donhead St Mary, Wilts (2008)
Mental Health Investigation
Mentally ill man fatally batters mother. Poor practice found
13 recommendations
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Independent investigation: Kamil Ahmad, Bristol (2016)
Mental Health Investigation
Paranoid schizophrenic with history of violence fatally stabs and mutilates refugee. Previous Rampton patient – released by Tribunal day before
14 recommendations
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Independent investigation: Lee Turner, Barnstaple (2018)
Mental Health Investigation
Paranoid schizophrenic with long history of mental illness fatally stabs complete stranger. Not taking Meds, family’s concerns unheeded
8 recommendations
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