Wales
NHS Region19 health investigations in the Wales region.
Independent investigation: Anthony Kitely, Cardiff (2009)
Mental Health Investigation
Schizophrenic man attempted to kill his mother then fatally and repeatedly stabbed his friend. Long MH history, recently released by MHRT against advice
15 recommendations
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Independent investigation: Brian Dodd, Prestatyn (2003)
Mental Health Investigation
Paranoid schizophrenic fatally and repeatedly (28 times) stabbed a stranger. V critical indep inq 2004, previously slashed strangers throat 1996. released 2000. Prev danger to others noted. Had stopped meds
22 recommendations
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Independent investigation: Caroline Evans, Llangadog, Camarthen (2003)
Mental Health Investigation
MH patient fatally shot victim then shot himself. Ind Inq 2005 – Previously sectioned for shotgun threat. Public protection not considered
37 recommendations
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Independent investigation: Cerys Yemm, Argoed (2014)
Mental Health Investigation
Mentally ill man fatally batters young woman. Recently released from prison with lack of aftercare
10 recommendations
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Independent investigation: Dean Shorney, Bargoed (2006)
Mental Health Investigation
MH patient fatally and repeatedly stabs victim.. Critical Ind Inq 2008. Known high risk of violence.
5 recommendations
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Independent investigation: Fr Paul Bennett, Aberdare (2007)
Mental Health Investigation
Paranoid schizophrenic repeatedly & fatally stabbed Priest (neighbour) frenzied attack. Ind Inq 2009
20 recommendations
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Independent investigation: Gwen Poole, Llanbradach, Caerphilly (2009)
Mental Health Investigation
Deluded Schizophrenic mentally ill man fatally stabs pensioner (stranger). Indefinite hospital order
-1 recommendations
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Independent investigation: James Fortey, Newport, Gwent (2007)
Mental Health Investigation
Schizophrenic fatally stabs former school friend. Critical Ind Inq 2009 – not assertive enough
6 recommendations
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Independent investigation: Jennifer Mills-Westley, Tenerife (2011)
Mental Health Investigation
Recent Welsh patient with schizophrenia fatally stabs grandmother. Inq found many failings in care
19 recommendations
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Independent investigation: John Rees, Pen Y Graig, Rhondda (2020)
Mental Health Investigation
Schizophrenic woman fatally stabs and bludgeons elderly shopper & attempted to murder three others. Had previously sought help for deteriorating Mental Health
7 recommendations
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Independent investigation: Karen Welsh, Cardiff (2010)
Mental Health Investigation
Paranoid Schizophrenic fatally beat and strangled nurse who befriended him. Sought help before killing
14 recommendations
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Independent investigation: Karina Menzies, Cardiff (2012)
Mental Health Investigation
Paranoid schizophrenic kills disabled young mother and injures 17 others. Long MH history, off meds, nearly killed 13 others including children
15 recommendations
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Independent investigation: Kenneth Auger, Merthyr Tydfil (2008)
Mental Health Investigation
Mentally ill man (bipolar) kills neighbour with a hammer. Repeatedly asked MH services for help – ignored
18 recommendations
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Independent investigation: Margaret Ford, Templeton, Pembs (2009)
Mental Health Investigation
Paranoid Schizophrenic fatally and repeatedly stabs mother then cuts her throat. Long MH History – Family critical
4 recommendations
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Independent investigation: Sandra Bowring (Vincent), Rhyl, Denbighshire (2006)
Mental Health Investigation
MH patient fatally stabs woman five times. Ind Inq 2008. Long MH history – failings – avoidable – High risk to others
13 recommendations
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Independent investigation: Stephen Rees, Cardiff (2011)
Mental Health Investigation
Paranoid schizophrenic fatally slashes hostel resident’s throat. Victim was also mentally ill
6 recommendations
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Independent investigation: Valerie Thomas, Cardiff (2005)
Mental Health Investigation
MH patient fatally stabs elderly stranger (2nd choice). Long MH history. Critical Ind Inq. No Risk ass. CCTV
6 recommendations
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The Path to Safer Beginnings in Wales: National Assurance Assessment of Maternity and Neonatal Services
Maternity and Neonatal
National assurance assessment of maternity and neonatal services across Wales, commissioned by the Cabinet Secretary for Health and Social Care in May 2025. Chaired by Professor Sally Holland (former Children's Commissioner for Wales). The panel visited maternity units throughout Wales and consulted hundreds of women, families and staff. Identifies strengths and vulnerabilities across capacity, culture, racism and discrimination, accountability, estates and workforce. All recommendations accepted by Welsh Government with three-year phased delivery programme.
28 recommendations
Report PDF
Investigation into matters relating to Jimmy Savile at Cardiff Royal Infirmary
Savile Hospital Investigation
Investigation into allegations of abuse by Jimmy Savile at Cardiff Royal Infirmary. Part of 44 NHS investigations commissioned by the Department of Health following revelations about Savile in 2012.