Mental health bosses have apologised for underestimating the risk posed by patients who went on to murder others, including failing to act on threats to kill.
Also under review was the death of Janet Muller, who was burned to death in the boot of a car after leaving Mill View Hospital by Christopher Jeffrey-Shaw last year.
The other cases included the infamous case of the burned body found on a Brighton golf course in 2010, for which Sean Iran was jailed for life, and Steven Dunne murdering Lewes Community Garden regular Gordon Stalker the same year, after he became convinced he was a witch who had captured his soul.
And the 2014 Christmas Day murder of Joe Lewis by Oliver Parsons and the “motiveless and brutal” murder of Jonathan Ellison in his Brighton flat by David Sole in 2011 were also reviewed.
Colm Donaghy, Chief Executive of Sussex Partnership said: “I want to start by saying sorry. The independent review we have published today relates to incidents which had devastating consequences for those affected.
“I realise this 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.
“We commissioned this review with NHS England because we want to make sure we have done everything we should have in response to these tragic incidents. The review sends us a very strong message about the need to identify and embed the learning from when things go wrong in a way that changes clinical practice and improves patient care. This goes beyond action plans; it’s about organisational culture, values and leadership.”
Jan Fowler, Director of Nursing and Quality at NHS England South (South Central) said: “We would like to express our deepest sympathies to all those affected by these tragic events. We worked with Sussex Partnership Trust to commission this review.
“The review did not re- investigate individual cases but instead 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 provided some recommendations for NHS England around how we can improve future investigations. We have already started work on these to ensure we have the right processes in place to help to improve care for patients.
“The review also identified a number of recommendations for Sussex Partnership NHS Trust. We will be working with Coastal West Sussex CCG, which commissions the mental healt services on behalf of other CCGs in Sussex, and Sussex Partnership NHS Trust to ensure therecommendations are acted upon and changes are made.”
The independent, thematic review of homicides involving patients known to Sussex Partnership NHS Foundation Trust between 2010 and 2015 was commissioned jointly with NHS England. Specific criticisms include the way care is planned for individual patients and involving carers and families.
It only covered five years because it would be difficult to extract and apply new learning from historical cases (i.e. longer than five years ago) given that services provided by Sussex Partnership have changed so significantly in recent years.
In this five year period, eight incidents occurred where the perpetrator was known to Sussex Partnership services and one incident where the victim was known.
One of the cases covered by the thematic review dates back to 2007 because the independent investigation process did not conclude until much later.
In one additional case, the victim of the homicide was known to Sussex Partnership, bringing the total number of cases covered by this review to 10.
The recommendations from the review can be summarised as follows:
- Monitor the implementation of the CDS (Care Delivery Service) structure and the use of the Safeguard Serious Incident recording system to ensure the investigation management and implementation of action plans are consistent with trust policies, processes and systems
- Provide assurance and evidence that learning from all recommendations is fully embedded across the organisation in a timely manner
- Ensure clinical staff have dedicated time for recording notes and record keeping; that staff record the rationale for the clinical decisions they make; and use risk assessment and formulation to inform relapse planning
- Investigate the feasibility of technological solutions to make it easier to complete records and improve productivity e.g. the use of voice recognition technology
- Develop a checklist of key requirements, based on the themes identified in this report, to be used at all CPA (Care Plan Approach) reviews
- Evaluate the impact of training and education
- Implement the ‘Triangle of Care’ approach to involving carers in the care and treatment of service users and achieve membership of the national programme within 12 month.
It’s about time they are investigated.I am a carer for someone who has metal health needs.He has been discharged as they have said there’s nothing they can do to help.Wont see him again unless he hurts himself.
The homicides are just the tip of the iceberg. Sadly, lots of suicides, unintentional deaths/overdoses, and many, many serious incidents among people with mental healthcare needs who are abandoned by the system. Many are “placed” into unsupported and unsafe accommodation by the council, to the detriment of everyone except the private landlords who charge a fortune.
Homicides and suicides will continue in MH until the authorities implement the genotype test prior to psychiatric medication prescibing. The test shows whether patients are able to metabolise the medications efficiently or otherwise. It is the inefficient metabolisers of psychiatric medication who go on to commit violence as their bodies are full of medication toxicities. It is not their fault. The fault lies with the statuatory and public bodies who since 2007 have swept this knowledge under the carpet. I think it is a disgrace when mental health experts abdicate thier reponsibilities to patients, carers and the public who are caught up in this mess.
I’ve been a pachanit many times in millview over the last 10 year’s and been sectioned on a few times my experiences have been mixed the staff try there best but its not run properly by the people upstairs my last time I was really unwell I cut my juggler throat 13 time’s and went to see the people upstairs but. They said no to my admission because I’d all ready harmed myself two weeks later I was sectioned and they had to admit me I was there for nearly six weeks thank God I saw my first psychiatrist and he put me on the right medication and I’ve not been back I still struggle with my mental health but I have a wonderful sister and a lovely home and I don’t want to go to hospital anymore. Godbless Paul groves