The purpose of an independent investigation is to discover what led to an adverse event and to audit the standard of care provided to the individual.

An independent investigation may not identify root causes or find aspects of the provision of healthcare that directly caused an incident but it will often find elements of care that could have been better provided.

Independent investigations are commissioned by NHS England.

These documents represent Part A and Part B of the full report for the independent investigation of the care and treatment of Mr X and the Lancashire Pathway Review. 

• Part A – Independent investigation into the care and treatment of Mr X

Following an incident in 2019, Mr X was charged with murder. Consequently, he was convicted of manslaughter and given a life sentence. He is currently detained in a high secure mental health hospital. At the time of the incident, Mr X was under the care of Lancashire and South Cumbria NHS FT. 

• Part B – Lancashire Pathway Review

In November 2020, NHS England commissioned a Pathway Review following significant similarities identified across a number of mental health homicide incidents and near misses within Lancashire and South Cumbria NHS FT. 

These are the Full Report, Associated Action Plan and Home Office Letter for the Joint Domestic Homicide Review and independent mental health homicide investigation in South Cumbria.

• Full Report
• Associated Action Plan
• Home Office Letter

The purpose of this important investigation is to gain a full understanding of clinical and patient outcomes as the result of care delivered by the Trust’s Urology Service.  The Investigation has identified areas for learning, as well as the identification of good practice, to ensure that a recurrence of the same or similar issues will be avoided in the future.

Final Independent Investigation Urology Report – University Hospitals of Morecambe Bay NHS Foundation Trust

Final Independent Investigation Urology Report Appendices – University Hospitals of Morecambe Bay NHS Foundation Trust

NHS England commissioned an independent investigation into Urology Services at University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB), which published its findings in November 2021. The investigation was independently conducted by Niche Health and Social Care Consulting.

The investigation identified learning and made recommendations to prevent recurrence of the events which led to the investigation being commissioned. Niche’s independent report and its recommendations have been instrumental in levering positive change for patients using the Urology Services at UHMB and for staff working in the Trust. NHS England are assured that Niche delivered on the Terms of Reference set out for this investigation into Urology Services. NHS England remain supportive of the independent investigation report published in November 2021, its findings and recommendations.

These are the Assurance Reviews of the actions taken by University Hospitals Morecambe Bay NHS Foundation Trust, NHS England, the General Medical Council, the Care Quality Commission and the Royal College of Surgeons and commenced 12 months following the publication of the independent investigation report in November 2021.  These Assurance Reviews were published in June 2023. 

Assurance Review: Trust recommendations

Assurance Review: Recommendations for commissioners, NHS England, advisors and regulators

An independent investigation into the care and treatment of Mr H

This is the executive summary of the independent investigation report into the care and treatment of Mr H.  At the time of his death Mr H was receiving care from Lancashire and South Cumbria NHS Foundation Trust.

This is the assurance review of the actions taken by Lancashire and South Cumbria NHS Foundation Trust and Lancashire and South Cumbria ICB following the publication of the independent investigation report in September 2021. This assurance review was published in July 2023.

Assurance review