NHS trust criticised for underestimating risk of patients who killed 10 people
Independent review into homicides that occurred between 2010 and 2015 criticised Sussex Partnership NHS foundation trust for misjudging danger
Denis Campbell Health policy editor
Tuesday 18 October 2016
An inquiry has criticised an NHS mental health trust for underestimating the risk of violence posed by patients who went on to carry out killings, two of which could have been prevented. Sussex Partnership NHS foundation trust has been criticised for not taking more seriously the families of disturbed patients who pleaded for help because they feared that their relative would commit violence.
The review of 10 homicides that occurred between 2010 and 2015 included the death of 79-year-old Donald Lock on the A24 near Worthing in Sussex in July 2015 after his car collided with that of Matthew Daley, who stabbed him 39 times.
An independent review of the trust’s handling of patients involved in the cases has found that it did not always learn from mistakes and on occasion “severely underestimated” the risk presented by certain patients. It was criticised for misjudging the risk posed in seven of the 10 killings.
In several cases, the process was said to be “inadequate and the risk posed by the service user went unrecognised or was severely underestimated”. Some diagnoses were acknowledged as flawed, yet were not changed even when patients carried out a fresh offence. “Sometimes service users made threats to kill others, but no further action – for example informing the police or warning the person threatened – was taken,” the report said.
The experts concluded that two of the 10 killlings could have been avoided, though they did not say which. The two did not include Lock’s death, for which 36-year-old Daley – who had a history of psychiatric problems including psychosis and who claimed diminished responsibility at his trial – was convicted of manslaughter.
The trust has already admitted that it “got things wrong” in Daley’s case and should have carried out a formal assessment of his mental state. Lock’s family say that he would “still be here today” if trust staff had done their job properly. Daley’s trial heard that his father warned doctors that unless his son received proper care for his condition, he would “hurt someone or worse”.
Colm Donaghy, the trust’s chief executive, apologised for incidents “which had devastating consequences for those affected. I realise this [review] may bring back painful memories for them. I also understand that some, if not all, will feel angry about our services. On behalf of the trust, I want to extend my sincere apology and condolences”.
A major NHS report earlier this month found that the number of killings by patients being treated for mental health problems is falling, probably as a result of improved NHS care. Patients with schizophrenia, psychosis or other disorders committed a total of 870 homicides across the UK between 2004 and 2014, which was just over one in ten (11%) of all killings in that time. Such homicides resulted in 67 deaths in 2014.
Sophie Corlett, director of external relations at the mental health charity Mind, said the NHS needed to do more to help those who feared that an unwell relative might harm themselves or others. “It’s vital that people are taken seriously when they say they are approaching crisis and ask for support. We still hear of too many cases where people have been turned away despite asking for help,” she said.
“If people don’t get support when they’re at their most unwell and vulnerable, there can be tragic consequences for people themselves, and sometimes – mercifully rarely – for others too. The lesson of this report is that these consequences can and should have been avoided.”
The trust jointly commissioned the review with NHS England to help it improve its handling of patients judged a risk to themselves or others.