Serious Incidents

Responding appropriately when things go wrong in healthcare is vital to make sure we can continually improve the safety of the services we provide to patients.

An incident requiring investigation is defined as an incident that occurred in relation to NHS-funded services and care resulting in unexpected or avoidable death, harm or injury to patient, carer, staff or visitor. In order to uphold quality and compliance, there are several reporting protocols for incidents, investigation and learning to improve systems and services across the organisation.

In the interests of learning and transparency, NHS England will publish and share independent investigation reports on its website and independent reports will also be published by the relevant local commissioner(s) and provider organisation(s).

Reports, action plans and assurance statements relevant to Leeds and York Partnership NHS Foundation Trust will be published on this page and updated until completion.

Latest Report and Statement

Report into the deaths of Kenneth Godward and Roger Lamb, and the care provided to Harry Bosomworth, 18 December 2018

Harry Bosomworth, a 70-year-old gentleman, attacked and seriously injured Ken Godward and Roger Lamb on ward J19 at Leeds Teaching Hospitals Trust on 28 February 2015. All three patients died within six months of the incident.

A statement has been published in response to two reports that investigated the circumstances surrounding this incident and the recommendations they make. Those reports were:

  1. A report by David Curtis jointly commissioned by Leeds and York Partnership NHS Foundation Trust (LYPFT) and Leeds Teaching Hospitals NHS Trust (LTH) which reviewed the care and treatment provided to Harry Bosomworth, published in April 2016.
  2. A report commissioned by NHS England entitled “An independent investigation into the care and treatment of Harry Bosomworth by Leeds and York Partnership NHS Foundation Trust and Leeds Teaching Hospitals Trust” published on 18 December 2018. This report has also been published on NHS England’s website.

LYPFT has published an assurance statement on actions it has taken in response to these reports: LYPFT-assurance-statement-relating-to-HB-KG-RL-18-12-2018

You can also read a full statement in response to these reports from our Chief Executive Dr Sara Munro on our website.

Previous reports and statements can be found below.
Ms K - 7 December 2018
Ms K

On 7 November 2018,  an independent report was published about the care of a patient known as Ms K who received mental health services from four organisations, including our Trust.  The report identified learning for all organisations involved.

We, along with all the other organisations involved, have used the learning to change and improve how we work. This includes closer working with other health and care providers to ensure continuity of care for individuals who move across different geographical boundaries and/or may be reluctant to engage with mental health services.

Our assurance statement: Assurance statement 2011-21879

MS - 14 November 2018

On 14 November 2018, an independent investigation report into the care of patient known as MS was published.

There are many lessons which we and other agencies have learned and implemented since this happened in 2015, including those set out in the investigation report.

We take our responsibilities to provide safe care seriously, working with our partners to take every action possible to learn from such tragic cases to prevent them from happening again.

Our Assurance Statement: Assurance statement 13271