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Our investigation reports

Where something has gone seriously wrong with a person's care and treatment we will undertake an investigation. Where there has been a serious deficiency in care and treatment we produce a report and make recommendations to services that should reduce the risk of a similar situation happening again.

Starved of care

Full report and summary report  from our investigation into the case of Mrs V,  a woman with dementia, who died in a general hospital in December 2008, following a short period of treatment. 

Loss of focus

Report from our investigation into the care and treatment of Ms Z a woman with psychosis, borderline personality disorder and alcohol problems who died while subject to a short term detention certificate.

Too close to see

Report from our investigation into the care and treatment of Mr F, a man who experienced mental illness in combination with alcohol misuse. Our investigation found a number of deficiencies in care and treatment which contributed to a serious incident and the death of Mr F's father.

Best of intentions

Report from our investigation into the care and treatment of Mrs I, an older woman with dementia. We we were concerned that despite regular contact with services Mrs I's mental and physical health had been allowed to seriously deteriorate before services intervened. Mrs I died shortly after being admitted to hospital on a guardianship order.

Wrong place, wrong time

Report of our investigation into the care and treatment of Ms Y, a young person aged 16. Our investigation focused on the lack of provision of specialist services for Ms Y while she was cared for in an adult psychiatric setting.