Case Studies
Real outcomes from our work across investigations, service design, safeguarding and operational improvement.
Young Adult Mental Health Case
A PSIRF-aligned investigation that gave a family clarity, and a Trust a practical route to safer leave governance.
The Ask
A large NHS Trust needed a fully independent, PSIRF-aligned investigation after a young man died during authorised leave from an inpatient mental health ward.
Outcomes
We delivered a clear, auditable chronology and systems-based analysis of contributory factors, reducing organisational risk and strengthening governance. The final report reflected the family's voice respectfully with practical, proportionate recommendations.
Community Mental Health Teams Review
A whole-system CMHT review that restored confidence after scrutiny, turning lived experience into an implementable improvement plan.
The Ask
Following a high-profile external enquiry, a regional system commissioned an independent review of Community Mental Health Teams across two localities.
Outcomes
The review produced a balanced, actionable assessment surfacing system-level themes and translating them into an implementable improvement plan covering standards, governance, leadership, risk management and continuity of care.
0–19 Service Modelling & Financial Sustainability
A defensible 0–19 demand, workforce and financial model, protecting statutory delivery while rebuilding sustainability.
The Ask
A provider under significant financial pressure needed an independent demand, capacity and financial model for its 0–19 service.
Outcomes
We delivered a unified, end-to-end 0–19 model meeting statutory KPIs under both low and high safeguarding pressure, alongside a clear workforce requirement and evidence of contract viability.
Domestic Homicide Review – Independent Health Investigation
A trauma-informed health investigation within a DHR, connecting three lived experiences into one clear safeguarding narrative.
The Ask
Within a high-profile DHR involving a mother and her two children, we were commissioned to deliver the independent health investigation.
Outcomes
The investigation provided a unified safeguarding analysis with clear learning themes and actionable recommendations to improve governance, coordination and safeguarding processes across the system.
Complex Multi-Agency Mental Health Pathway
A national safeguarding investigation that made a fragmented 15-month pathway intelligible.
The Ask
A national body commissioned an independent safeguarding investigation into the care of a young woman with significant trauma history and complex mental health needs.
Outcomes
We produced an authoritative, integrated report with unified safeguarding analysis and practical recommendations supporting local improvement and broader strategic insight for national assurance.
Four-Year Care Pathway Investigation
A four-year mental health pathway put under the microscope — PSIRF-aligned learning services could actually implement.
The Ask
Commissioned by a national body to investigate four years of mental health care for a young adult following a serious incident.
Outcomes
The work translated complex evidence into clear findings and SMART recommendations, strengthening clinical governance, improving family engagement frameworks and clarifying multi-agency pathways.
Independent Workplace Investigation
A sensitive allegation handled with rigour: independent fact-finding that protected people and strengthened organisational grip.
The Ask
A community health provider commissioned an independent management investigation following concerns about inappropriate out-of-hours messaging within a reporting relationship.
Outcomes
Using structured methodology aligned to internal policy and ACAS guidance, the investigation gathered evidence and concluded with a clear recommendation via the organisation's formal disciplinary process.