Investigation reports

Here you will find links to investigation reports published by the Healthcare Commission.

More information about investigations, including current investigations

Learning from investigations

The Healthcare Commission has reviewed all the investigations it has undertaken from August 2004 to April 2007. Report published 4 February 2008:

Learning from investigations (pdf 1418kb) (opens new window)

Investigation into Staffordshire Ambulance Service NHS Trust

An investigation to establish whether the trust has adequate systems and processes in place to ensure the safety of patients.
Investigation commenced on January 24th 2007.

Investigation into Staffordshire Ambulance Service NHS Trust - April 2008 (pdf 946kb) (opens new window)

Action plan by West Midlands Ambulance Service NHS Trust following the Healthcare Commission's investigation into Staffordshire Ambulance Service NHS Trust - April 2008 (pdf 266kb) (opens new window)

More information about Staffordshire Ambulance Service NHS Trust

Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust

Report of the Healthcare Commission's visit to Maidstone and Tunbridge Wells NHS Trust on 12 and 13 December 2007 (pdf 59kb) (opens new window)

Published: 11 October 2007
Investigation report: Maidstone and Tunbridge Wells NHS Trust (pdf 1724kb) (opens new window)

Executive Summary Action plan following outbreaks of Clostridium Difficile at Maidstone and Tunbridge Wells NHS Trust for the period October 2005 - September 2006 (opens new window)

More information about Maidstone and Tunbridge Wells NHS Trust

Investigation into cardiothoracic surgical services at the Oxford Radcliffe Hospitals NHS Trust

Published: 28 March 2007

Investigation report: Oxford Radcliffe Hospitals NHS Trust (pdf 1086kb) (opens new window)

Action plan by Oxford Radcliffe Hospitals NHS Trust in response to the Healthcare Commission's investigation into cardiothoracic surgical services at the trust (pdf 157kb) (opens new window)

More information about Oxford Radcliffe Hospitals NHS Trust

Investigation into the service for people with learning disabilities provided by Sutton and Merton Primary Care Trust

Published: 17 January 2007

Main investigation report (pdf 1216kb) (opens new window)

Summary of the investigation (pdf 673kb) (opens new window)

Easy read summary of the investigation (pdf 2082kb) (opens new window)

Action plan by Sutton and Merton PCT in response to the Healthcare Commission's investigation into services for people with learning disabilities at the trust (pdf 191kb) (opens new window)

Press release: Healthcare watchdog review finds progress in standards of services for people with learning disabilities at Sutton and Merton Primary Care Trust

Summary report from the one-year follow-up visit to Sutton and Merton Primary Care Trust (pdf 136kb) (opens new window)

A report about the second visit to Sutton and Merton Primary Care Trust (Easy Read report) (pdf 590kb) (opens new window)

More information about Sutton and Merton Primary Care Trust

Investigation into 10 maternal deaths at, or following delivery at, Northwick Park Hospital, North West London Hospitals NHS Trust, between April 2002 and April 2005

Published: 23 August 2006

Investigation into 10 maternal deaths at, or following delivery at, Northwick park Hospital, North West London Hospitals NHS Trust, between April 2002 and April 2005 (pdf 920kb) (opens new window)

More information about North West London Hospitals NHS Trust 

Investigation into outbreaks of Clostridium difficile at Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust

Published: 24 July 2006

Investigation into outbreaks of Clostridium difficile at Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust (pdf 1331kb) (opens new window)

Download action plan by Buckinghamshire NHS Trust in response to the Healthcare Commission's investigation into outbreaks of clostridium difficile at Stoke Mandeville Hospital, July 2006 (pdf 323kb) (opens new window)

Published: 15 November 2007

Progress made since July 2006 investigation (pdf 176kb) (opens new window)

More information about Buckinghamshire Hospitals NHS Trust

Investigation into services for people with learning disabilities at Cornwall Partnership NHS Trust

Published: 5 July 2006

Investigation into the provision of services for people with learning disabilities at Cornwall Partnership NHS Trust - report (pdf 831kb) (opens new window)

Investigation into the provision of services for people with learning disabilities at Cornwall Partnership NHS Trust - Easy read (pdf 649kb) (opens new window)

Action Plan for the Health and Social Care community of Cornwall in response to the Joint investigation into the provision of services for people with learning disabilities at Cornwall Partnership NHS Trust by the Healthcare Commission and the Commission for Social Care Inspection (pdf 315kb) (opens new window)

Published: 28 March 2008

Cornwall Partnership NHS Trust: Review of progress following the Healthcare Commission’s investigation (pdf 84kb) (opens new window)

Cornwall Partnership NHS Trust: Review of progress following the Healthcare Commission’s investigation - Easy read summary (pdf 380kb) (opens new window)

More information about Cornwall Partnership NHS Trust

Investigation into the care and treatment given to Christopher Alder by Hull Royal Infirmary and Humberside Ambulance Service NHS Trust prior to his death

Published: 27 March 2006

Investigation into the care and treatment given to Christopher Alder by Hull Royal Infirmary and Humberside Ambulance Service NHS Trust prior to his death (pdf 1267kb) (opens new window)

Download action plan for Tees, East and North Yorkshire Ambulance Service in response to the Commission's Investigation into the care and treatment given to Christopher Alder by Hull Royal Infirmary and Humberside Ambulance Service NHS Trust prior to his death (pdf 27kb) (opens new window)

Download action plan for Hull & East Yorkshire Hospitals NHS Trust in response to the Commission's Investigation into the care and treatment given to Christopher Alder by Hull Royal Infirmary and Humberside Ambulance Service NHS Trust prior to his death (pdf 30kb) (opens new window)

More information about Hull & East Yorkshire Hospitals NHS Trust

More information about Tees East and North Yorkshire Ambulance Service NHS Trust

Mid Cheshire Hospitals NHS Trust

Published: 24 January 2006

Investigation into Mid Cheshire Hospitals NHS Trust (PDF, 710K) (opens new window)

Terms of reference for the investigation (PDF, 80K) (opens new window)

Action plan for Mid Cheshire Hospitals NHS trust Healthcare Commission Investigation (xls 88kb) (opens new window)

More information about The Mid Cheshire Hospitals NHS Trust

East Sussex Hospitals NHS Trust

Published: 9 August 2007

Investigations Committee report (pdf 35kb) (opens new window)

Investigation action plan (pdf 86kb) (opens new window)

Working locally engagement form (pdf 38kb) (opens new window)

Published: 12 January 2006

Investigation into allegations of bullying and harassment and the process for handling complaints at East Sussex Hospitals NHS Trust (PDF, 285K) (opens new window)

Action plan following the investigation into allegations of bullying and harassment and the process for handling complaints at East Sussex Hospitals NHS Trust (PDF, 103K) (opens new window)

Terms of reference for the investigation (PDF, 73K) (opens new window)

More information about East Sussex Hospitals NHS Trust

Devon Partnership NHS Trust

Published: 12 January 2006:

Download Allegations of bullying and harassment at Devon Partnership NHS Trust (PDF, 303K) (opens new window)

Download Devon Partnership NHS Trust - Action plan (pdf 109kb) (opens new window)

More information about Devon Partnership NHS Trust

The North West London Hospitals NHS Trust

Published: 7 July 2005

Download Review of maternity services provided by North West London Hospitals NHS Trust (PDF, 372K) (opens new window)

Download Action plan arising from a responsive review of Maternity Services (PDF, 247K) (opens new window)

Download Department of Health action plan (PDF, 21K) (opens new window)

More information about North West London Hospitals NHS Trust

Bolton, Salford and Trafford Mental Health NHS Trust

Published: 18 May 2005

Download Investigation into drug dependency services provided by Bolton, Salford and Trafford Mental Health NHS Trust - report (PDF, 188K) (opens new window)

Download Investigation action plan (PDF, 237K) (opens new window)

Download Terms of reference for the investigation (PDF, 78K) (opens new window)

More information about Bolton, Salford & Trafford Mental Health NHS Trust

Mid Yorkshire Hospitals NHS Trust

Published: 16 December 2004:

Download Investigation into Mid Yorkshire Hospitals NHS Trust - report (PDF, 302K) (opens new window)

Download Terms of reference for the investigation (PDF, 71K) (opens new window)

More information about Mid Yorkshire Hospitals NHS Trust

The Royal Wolverhampton Hospitals NHS Trust

Published: 16 June 2004:

Download Investigation of the maternity service provided by the Royal Wolverhampton Hospitals NHS Trust at New Cross Hospital, full report (PDF, 268) (opens new windowK)

Download Investigation summary into maternity services provided by the Royal Wolverhampton Hospitals NHS Trust at New Cross Hospital (PDF, 183K) (opens new window)

Order a hard copy of the summary report (opens new window)

Download Royal Wolverhampton Hospital Trust action plan in response to the investigation published 16 June 2004 (PDF, 276K) (opens new window)

Download Wolverhampton Primary Care Trust action plan in response to the investigation published 16 June 2004 (PDF, 58K) (opens new window)

Download Department of Health action plan in response to the investigation (PDF, 24K) (opens new window)

More information about The Royal Wolverhampton Hospitals NHS Trust

Investigation reports published by the Commission for Health Improvement (CHI)

Reports published prior to 1 April 2004.

Investigation reports published by CHI

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