Independent reports - previous

All previous reports can be found below

2010

Report of the Independent Investigation into the care and treatment of Mr SN.

This is a report of the Independent Investigation into the circumstances
surrounding the treatment and care of Mr SN who had been in receipt of mental health services, latterly provided by Avon and Wiltshire Mental Health Partnership NHS Trust since 1990.  Mr SN was convicted of the murder of Mr Philip Hendy, whom he had fatally stabbed on 29 April 2007.  

2011

Independent Investigation into the Care and Treatment Provided to Mr. X by the Lincolnshire Partnership NHS Foundation Trust and the Avon and Wiltshire Mental Health Partnership NHS Trust

This Investigation was asked to examine a set of circumstances associated with the deaths of Mr. and Mrs. X senior, the parents of Mr. X, who were found killed on the 11 July 2007.  Mr X was unfit to plead but was found responsible for the killings by a Crown Court jury.

Report of the Independent Investigation into the care and treatment of Mr MH

This Investigation was asked to review the care and treatment afforded to MH during the period of his contact with NHS services provided by Avon and Wiltshire Mental Health Partnership NHS Trust from September 2004 until March 2007 when the homicide occurred.   MH killed CJ on 4 March 2007.  He was convicted of manslaughter by reason of diminished responsibility.

2012

Review of governance and management arrangements at Avon and Wiltshire Mental Health partnership NHS Trust on behalf of NHS South of England ('The Sutherland Report')

This review (published 26.07.12) was commissioned by NHS South of England following investigation reports into the care given to two unrelated service users of the Trust who were involved in homicides. The Board of NHS South of England requested a review in order to be assured that corporate and clinical governance arrangements, clinical leadership and wider stakeholder engagement were robust and patient safety assured.

The full report was published by NHS South of England and is now available here.

Fit for the Future
The AWP Board accepts the report. To address the issues raised in the report, which was written in January,  a comprehensive action plan (Fit for the Future) was simultaneously published. The action plan sets out how the Trust will improve to better meet the needs of patients. (see right)

A summary of the main points in both the report and the action plan is also available.

Independent Investigation into the Homicide of Mr A by Mr B

This independent investigation team  looked at the care and management of the mental health service user Mr B (at the time an outpatient and community mental health service user of Avon and Wiltshire Mental Health Partnership NHS Trust) who assaulted his stepfather and his mother in the family home.  His stepfather died at the scene and Mr B was subsequently convicted of the manslaughter on the grounds of diminished responsibility.

Independent Investigation into the Care and Treatment Provided to Mr Y by the Cornwall Partnership NHS Foundation Trust,  Cornwall Council and Avon and Wiltshire Mental Health Partnership NHS Trust

This Investigation was asked to examine a set of circumstances associated with the death of Mr Y in 2007 who received care and treatment for his mental health condition from the Cornwall Partnership Mental Health Trust (Cornwall Partnership NHS Foundation Trust) and for a seven month period in 2004, from Avon and Wiltshire Mental Health Partnership NHS Trust.  Mr Y was convicted of manslaughter and also detained under the Mental Health Act.

2013

Interim review of progress towards organisational change ('The Sutherland Report 2')

In June 2012 an independent review of governance and management arrangements at the Trust (the Sue Sutherland report) was commissioned by the former Strategic Health Authority (NHS South of England) following concerns raised in two mental health homicides reviews.
 
The report contained significant criticism of the Trust and led to major changes within the organisation. 
 
Earlier this year (2013) the Trust and local health commissioners commissioned the same report team to undertake a further review to assess progress to date.
 
The review team's report has now been completed and it concludes that "at Trust and locality level we observed the organisation to be completely different and unrecognisable from our previous visits in a very positive way.

In addition to the report, a summary briefing note is available here.

The 2013 report can be accessed here.
The 2012 report can be accessed here.

Independent investigation into the care and treatment provided to Mr X

The independent investigation team examined the circumstances associated with the death of Mr C on the 11/12 April 2008.  Mr X received care and treatment for his mental health condition from Avon and Wiltshire Mental Health Partnership NHS Trust between May 2005 and 8 April 2008.  Mr X was convicted at Winchester Crown Court in November 2008 of manslaughter on the grounds of diminished responsibility and detained for an indeterminate period under the Mental Health Act (1983).

Executive summary here

Independent investigation into the care and treatment provided to Mr Y

The independent investigation team examined the circumstances associated with the death of Mr H on the 7 May 2008.  Mr Y received care and treatment for his mental health condition from Avon and Wiltshire Mental Health Partnership NHS Trust (the Trust) between October 2001 and May 2008.  Mr Y was convicted in July 2008 at Bristol Crown Court of the murder of a man in North Somerset, and sentenced to life imprisonment.

Executive summary here

Independent investigation into the care and treatment provided to Mr Z

The independent investigation team examined  the circumstances associated with the death of Mr A on 24 May 2008.  Mr Z received care and treatment for his mental health condition from Avon and Wiltshire Mental Health Partnership NHS Trust between September 2002 and May 2008.  Mr Z, who was found guilty of manslaughter at Bristol Crown Court on 14 April 2009, was sentenced to 11 years' imprisonment following the killing of a man in Bristol in May 2008. 

Executive summary here

2014

NHS England has published the report on the independent investigation into the care and treatment of Mr MC and the homicide of Mr GN which took place in Bristol in 2012.

The report is now available on the Trust website while our response to the Niche Independent Inquiry is available here.

SW Regional Health Authority reports

The following two reports were commissioned and considered by the former South West Regional Health Authority which operated in the south region, but were not published before it was abolished on 31st March 2013. NHS England published them on 14 April 2014.

The reports relate to:

2016

Independent report published

NHS England has published their commissioned report of an investigation to assess the care provided by Avon and Wiltshire Mental Health Partnership NHS Trust over the period of eight years from the point when Rachel (not her real name), the patient, was first referred to the Trust, to the point when she was charged with arson and murder of Mr. Y on 10 September 2014.

The full report can be read here.

The Trust action plan can be read here.

Independent report published

Bristol Safeguarding Adults Board has published their report following the death of Simon Reynolds on 21 November 2014.

The executive summary can be read here

Associated information can be found here

2018

An independent investigation was commissioned by NHS England following an internal investigation completed by Hertfordshire Partnership University NHS Foundation Trust into the events leading up to the death of Ms M (not her real name). Alongside this, a Multi Agency Partnership Review into the death of Ms M was commissioned by Hertfordshire Adult Safeguarding Board. The aim of this investigation is not to investigate the circumstances of the offence, but to enable the providers of care, and the whole of the NHS, to learn lessons and make improvements for the benefit of future patients, their carers and the public. These reports are commissioned so that the NHS is open and transparent with the families involved and the wider public about what took place and what the NHS is doing to address any issues raised. The investigation team's view is that the incident could not have been predicted with any degree of certainty that would have made it possible to prevent.

Read the full documents, including the final report, the action plan, AWP's action plan and media statement below.

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