Independent Investigation Reports Published

Posted on 28th July, 2011

Devon Partnership NHS Trust has accepted the findings of independent investigations into four unrelated homicides that took place between 2006 and 2007. The four reports were published today by the South West Strategic Health Authority.  In three of the cases, the investigations found that the homicides could not be directly attributed to any individual or corporate failing and, in each of these cases, the individuals were deemed to be responsible for their actions and prosecuted though the criminal justice system.  In one of the cases (referred to as Mr RD), the investigation concluded that the homicide could have been prevented.  Mr RD was made the subject of a hospital order and is currently in a medium secure hospital. Commenting on the reports, Dr Helen Smith, Co-Medical Director at Devon Partnership NHS Trust, said:  “Each of these cases is tragic and, on behalf of the Trust, I offer my heartfelt sympathy to the families concerned.  “In the case of Mr RD, the report acknowledges that the Trust provided considerable help and support and that his reluctance to engage with services, failure to comply with medication and regular use of illicit drugs and alcohol posed significant challenges to those people working with him.  However, the report concludes that the homicide could have been prevented if the Trust had acted upon the concerns expressed by family members and taken more assertive action to assess Mr RD’s mental health in the days leading up to the incident.  “This case is particularly tragic as it involves the death of loving grandmother at the hands of a grandson to whom she had been devoted and it has, understandably, had a profound impact upon the whole of the family. “It is the first time in the Trust’s history that a direct link has been established between the quality of care we have provided and a tragedy of this kind.  It has had a significant impact upon the staff concerned and the organisation as a whole.  The Trust apologises unreservedly for the failures in care identified in this case and we take the conclusions and recommendations set out in the report very seriously indeed.  “We have been working closely with the authors of the reports for some time now and, since the incidents occurred, a number of very important changes have been made.  The Trust’s systems for planning and coordinating care have been fundamentally revised; clear standards have been set; training has been given across the whole organisation and compliance with these standards is now regularly monitored.” Among the key actions already taken by the Trust are:

  • New arrangements and training to assess and provide services for people with both a severe mental illness and an alcohol or drug addiction (known as a dual diagnosis)
  • The introduction of a new records management policy and procedures and the implementation of a new, Trust-wide electronic patient records system
  • The risk management policy has been reviewed and renewed and the assessment and management of risk is now monitored more rigorously across the organisation, including within those services for people with an alcohol addiction
  • Much stronger arrangements for the reporting, management and follow-up of all serious untoward incidents, including the introduction of the Root Cause Analysis process, which is encouraged nationally as best practice.
Dr Smith added:  “These cases all happened several years ago and, despite the fact that the reports have been published together, they are unrelated.  I would like to reassure people that the risk of any act of violence being carried out by a person with mental health needs is very small indeed.     “Evidence tells us that even people with the most severe mental health problems are far more likely to pose a risk to themselves than they are to other people.  We also know that, in Devon, the number of serious incidents involving people who have recently been in touch with mental health services is no higher than we would expect to see.” Note to editors 1. Anonymity and use of photographs It is standard practice that reports of this kind do not include the names of those involved. These homicides took place between 2006 and 2007.  Revisiting them for the purposes of these reports has been a traumatic experience for some family members of both the perpetrators and the victims. Although we understand that the media may be able to establish their identities through previous coverage of these cases, we politely request that you refrain from using photographs in any coverage of the reports, or let us know if you plan to do so in order that we can inform the families concerned in advance.  Thank you.  Ends S043      For further information contact Peter Leggatt on 01392 208693.