Independent Investigations

Independent review of mental health treatment and care provided in Dorset and Nottinghamshire

NHS England has published an independent investigation report into the treatment and care of ‘Mark’, who killed his step-grandfather after moving from Nottinghamshire to Dorset in 2018.

Dorset HealthCare has already taken steps to improve procedures and practices since the time of this incident. We have also developed and are implementing an action plan in response to the findings of the NHS England report.


On 21 September 2016 NHS England published a homicide report into the care and treatment of Mr X, Ms Y and Mr Z. The individuals involved in this case were known to Dorset HealthCare and tragically Mr X lost his life. Following the full investigation by the Health and Social Care Advisory Service (HASCAS) recommendations were made from the learning identified.

The recommendations concern the development of improved care pathways and better sharing of information between health organisations and other service providers. An action plan has been developed and we have been working together to address the shortcomings and will continue to do so to ensure that future patient care is improved.

Corporate Documents