Homicide Investigation Report into the death of a child.




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Birmingham Cross City Clinical Commissioning Group


Technical Report

Peer reviewed


When serious incidents occur the National Health Service (NHS) has a responsibility to ensure that an appropriate investigation takes place. The purpose being to review the circumstances which may have led to the serious incident, identify root causes, and highlight areas where improvements can be made in order to minimise the risk of such events happening in the future (National Patient Safety Agency (NPSA) 2010 & NHS Commissioning Board (NCB) 2013). In accordance with the National Serious Incident Framework (NPSA 2010 and NCB 2013) Birmingham & Solihull Mental Health NHS Foundation Trust commenced a serious incident investigation into the circumstances surrounding the care and treatment of P. The investigation panel worked to the agreed Terms of Reference, but also addressed the questions raised in Court by The Honourable Mrs Justice Thirlwall DBE. The investigating panel urge all organisations, but especially those organisations that have not reviewed their part in the life of P, to do so with reference to this investigation report. The report highlights a significant number of issues for consideration with some key themes emerging.


This was a confidential investigation requested by Birmingham Cross City CCG on behalf of Birmingham & Solihull Mental health Foundation Trust. The investigation covered several NHS organisations, primary and secondary care, acute and mental health Trusts, Court services Social Services, Probation services, schools & HM Prisons. Following the report tow MPs asked questions in the House of Commons regards the implications from the failings identified by the investigation.


Report, Homicide, Mental Health Provision


Reed, A, Illingworth, P, Byford, N, Billings, G and Thompson, E. (2014) Homicide Investigation Report into the death of a child. Reprt Ref STEIS Reference 2013/7122. Birmingham Cross City Clinical Commissioning Group


Research Institute

Institute for Allied Health Sciences Research
Mary Seacole Research Centre