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Our investigations

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  • 8 September 2016
    Publication, Investigation report, Perinatal

    The full report on our investigation into the death of Baby A who died at nine months old. Baby A was suffocated by her mother, Ms OP, who had a history of postnatal depression following a previous pregnancy.

  • 27 January 2016
    Publication, Investigation report

    The full report of our investigation on Ms MN, a 44 year old woman with complex needs, who died after hanging herself in the care home to which she had recently been moved.

  • 27 January 2016
    Publication, Investigation report

    Our executive summary of our investigation into the death of Ms MN, a 44 year old woman with complex needs who hanged herself in the care home to which she had recently been moved.

  • 8 July 2014
    Publication, Investigation report

    The full report on our investigation into the end of life support and treatment of Mr JL.

  • 8 July 2014
    Publication, Investigation report

    An executive summary of our report into the end of life support and treatment of Mr JL.

  • 8 April 2014
    Publication, Investigation report

    A short summary report on the case of Mr GH. His partner tried to get care for Mr GH but was not listened to. Mr GH was then involved in an incident at his workplace.

  • 26 March 2014
    Publication, Investigation report

    Our report on our investigation involving a woman who sadly took her own life. She had recently had a work capability assessment from the DWP and we look into the process of this.

  • 24 March 2014
    Publication, Investigation report

    A short report into the care and treatment of Ms FG. Ms FG did not receive enough support when she was very unwell and was involved in a serious incident.

  • 24 February 2014
    Publication, Investigation report

    Our investigation into the care and treatment of Mrs CD. Mrs CD was remanded to prison following a breach of the peace. Concerns were raised with us because prison healthcare staff felt she should be in hospital not prison.

  • 3 February 2014
    Publication, Investigation report, Learning Disability

    Our investigation into the care and treatment of Mr S. Mr S is a man with learning disabilities who was repeatedly offending. We were concerned that services could not agree on how to prevent this.

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