Independent Investigation of Ms C

NHS England commissioned an independent investigation into the care and treatment of Ms C.

Ms C pleaded guilty to manslaughter on the grounds of diminished responsibility following the tragic death of her neighbour in October 2018. At the time of the incident Ms C had been under the care of mental health services provided by our Trust.

Although the report did not find that there were any lapses in care that directly attributed to the incident, areas for improvement were identified and a number of recommendations for improvement, including changes of practice, have been made. We welcome recommendations to improve our services and continue to deliver the agreed action plan to ensure these changes are embedded in our services.

Michele Moran, Chief Executive at Humber Teaching NHS Foundation Trust, said:

“I would like to offer my sincere condolences to the families and everyone affected by this tragic event. Alongside a thorough internal investigation, we fully participated with the independent investigation commissioned by NHS England. Upon accepting the recommendations made in the July 2021 report, we have completed all suggested actions and support a culture of continuous improvement throughout our Trust services.”

The independent investigation into the care and treatment of a mental health service user Ms C was published July 2021.

The independent quality assurance review of the implementation of recommendations resulting from this independent investigation was published August 2022.

Both documents are available in the Downloads section below.