Independent Investigations

An independent investigation into the care and treatment of a mental health service user, Mr T – published 6 January 2022

Mr T and his son died in 2016. The report explores the care of Mr T and the circumstances surrounding the death of his son. We would like to express our condolences to their family.

Since 2016 we have acted to address all the recommendations. These include reviewing and strengthening the processes and policies on duty of candour, engaging with families, and children’s safeguarding.

Read the  Mr T Independent Investigation Report [pdf] 3MB
Read the Mr T action plan [pdf] 184KB

An independent investigation into the care and treatment of a mental health service user, Mr P - published 28 July 2020

Mr P was a patient of the Trust between June 2015 and April 2016. Mr P was found guilty of manslaughter by diminished responsibility in August 2017, following the stabbing of Ryan Merna a year earlier in August 2016.​ We would like to express our condolences to Ryan’s family.

We have responded to the single recommendation for the Trust in the report to improve communication between areas when patients relocate to ensure continuity of care.

Following the report on Mr P, an independent quality-assurance review on implementation of its recommendations has been published.

An independent investigation into the care and treatment of a mental health patient Mr M - published 20 February 2019

We published an independent investigation report and resulting action plan related to the care and treatment of Mr M, who was a patient under the care of Trust at the time of his death. Mr M and his wife were found dead at home in March 2016 and our condolences are with the family and friends. Following the report on Mr M, an independent quality-assurance review on implementation of its recommendations has been published.