This independent review investigates the care and treatment provided to Mr L between 2012 and 2016.

The purpose of this investigation was to determine if different action by any of the health agencies involved with N and Mr L could have avoided, or reduced, the opportunity of the tragic incident leading to N’s death.

The review was undertaken by national investigations company, Consequence UK Ltd.  The two independent reviewers in this case were Maria Dineen, Managing Director of Consequence UK Ltd and Nicholas Chamberlain Kent.

Here is the full report and our improvement action plan.  All actions have been completed.