The aim of this report is to help improve the delivery of care for people who are at risk of self-harm.
Mr B was a 50-year-old man who had been living with secondary progressive multiple sclerosis (MS) for over 20 years and was living in a care home.
On 27 May 2023, Mr B left the assessment unit of Brook Meadows House (BMH) where he had been living since 10 June 2022, and travelled to Kent, where he ended his life.
The final report and action plans can be found on the NHS England website:
NHS England: Independent investigation reports for East of England