Report highlights NHS lapses before killings involving mental health patients

Lapses at an NHS trust have been highlighted after 10 killings involving mental health patients

An independent review found that a lack of risk assessments and unchanged diagnoses preceded the deaths in Sussex between 2007 and 2015.

The review was carried out to assess the Trust’s response to homicides involving people under its care

Jan Fowler

Sussex Partnership NHS Foundation Trust co-commissioned the review with NHS England.

Between 2010 and 2015, eight incidents occurred where the perpetrator was known to Sussex Partnership services and one incident where the victim was known.

The other incident took place in 2007 when Roger Goswell killed his wife, Susan, in West Chiltington, before taking his own life.

The review was launched following the killing of Don Lock, 79, from Worthing, who was stabbed 39 times by Matthew Daley in December 2015.

Daley, who has been diagnosed with paranoid schizophrenia, was given a life sentence for manslaughter on the grounds of diminished responsibility earlier this year after being charged with murder.

Reports said that sometimes diagnoses were incorrect and remained unchanged after user’s behaviour changed.

It added that sometimes threats to kill others were made but no further action was taken and risk assessments were sometimes completed incorrectly or not at all.

Jan Fowler, Director of Nursing and Quality at NHS England South, said: ‘The review was carried out to assess the Trust’s response to homicides involving people under its care, to identify any common themes and learn lessons to help improve patient care and public safety in the future.’

The review has recommended monitoring the implementation of the Care Delivery Service structure and the use of the Safeguard Serious Incident recording system.

It also recommends to ensure that clinical staff have dedicated time for recording notes and record keeping.

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