Three major opportunities were missed to assess risks posed by a paranoid schizophrenic who repeatedly stabbed a young woman in a supermarket, according to a report published today.Oh, boy. Here we go…
The first was when he was first admitted to psychiatric services in August 2007, after assaulting two female strangers on the same day, with each occasion involving a weapon.
'The motivation underlying the assaults and the significance of his associated symptoms were never fully explored,' the report says.
The second opportunity was when he was transferred to the rehabilitation and recovery unit after five months on the acute admission ward. The report says: 'Assessment of risk was incomplete and the potential seriousness of the two assaults on the women prior to admission was still not fully appreciated.'
The third major opportunity was when he was readmitted to the acute mental health ward after the re-emergence of psychotic symptoms including thoughts of killing people.
'In addition, Mr Z had expressed dissatisfaction with his medication on a number of occasions and had asked to change it. The management plan at this stage contained no specific strategy to manage the increased level of risk of harm to others that Mr Z posed,' the report says.And that’s not all. We see the usual lack of interest in anything outside the narrow world of the psychiatric ward:
In addition to the three 'pivotal points' where opportunities were missed, there was also little evidence of staff attempting to establish a relationship with his mother, who was a very important part of his future care plan, the report says.
'In spite of Mr Z’s extensive periods of leave to his mother and older brother’s addresses neither was approached for their views as to the success or otherwise of these arrangements.'They are just civilians, after all. Leave it to those who know best!
Naturally, the NHS staff swing into ‘Oh, but…’ mode:
Liz Redfern, director of nursing at NHS South of England, said after publication of the report: 'It is important to remember that this attempted murder took place in 2008.
'I want to emphasise that the learning and the improvement of services by Sussex Partnership NHS Foundation Trust began to take place as soon as the outcome of the initial investigation (by the trust) was known. The outcome of this full independent investigation has continued to influence ongoing improvements.'Yeah, yeah, yeah. It’s not like we haven’t heard all this before, is it?
Dr Shakil Malik, clinical director and consultant psychiatrist at the Sussex Partnership NHS Foundation Trust, said it was 'deeply sorry' about the incident.
'Thankfully, cases like this are rare but when they do happen we are committed to learning everything we can from them in order to minimise the chances of similar incidents happening in the future.
'In our review, we found that staff had been compassionate and caring, but in hindsight, they had also been too hopeful and naive. '*sigh*
He added that it was an 'exceptional' case.Errr, no. It’s far from that. It seems to happen quite a lot.
With the hindsight of the two investigations, one could not categorically say the attack was preventable or predictable, he added. 'He told the investigation team that he had been planning this for a few weeks but kept it to himself and didn’t tell the staff. He was able to hold a conversation, he had sanity. It was a difficult, complex, unusual case.'You mean, mental patients can be cunning and lie to staff? And this is news to you? Amazing!
I guess the naivety goes all the way to the top, eh?
Marjorie Wallace, chief executive of the mental health charity Sane, said: 'This report finds a number of mistakes, but we think it is an understatement of the gross misjudgments made of a man with a history of violence to women and expressed intentions to kill.
'The findings of the independent inquiry are truly shocking in the opportunities missed to protect both a patient and the public, in the face of clear warning signs that he had both a history of attacking women, called himself a serial killer and expressed the intent of killing women.
'He was also known not to be taking the medication that could control his paranoid delusions. Despite this, he was allowed to live in the community, from where he attacked and severely injured Lucy Yates.
'One of the most disturbing findings is that the care team listened only to the patient’s views and cold-shouldered any attempt by his mother and brother to help in his care and treatment.Mmmm. That wouldn’t be because mental health charities – Hey! Like yours! – emphasise how it’s the individual who is the most important one, the one with all the rights, would it?