Various circumstances can dictate the need for an independent investigation in to the NHS care and treatment of a mentally ill person. This can include homicide by an existing mental health patient but there is also wider discretion to determine that such an investigation is necessary. The pages linked here provide links to many independent reports as well as annual summary reports for some regions / years.
I’m in the process of reading through many of them —
The Health and Social Care Act 2022 has brought a change to how some of these matters are commissioned and published. Some of the pages linked above, make this explicit and the pages only contain reports up to the middle of 2022. Others contain much more recent reports, such as those commissioned in the North-East in to the hospital scandal at West Lane Hospital in Middlesbrough.
I submit, as with Preventing Future Death reports from UK coroners, that there is a wealth of information as well as potential for lessons learned, within the material available from these links.
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award

All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2022
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk