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Review uncovers failings at mental health trust

A review of 10 killings has uncovered failings at a mental health trust.
Sussex Partnership NHS Foundation Trust logo

A review of 10 killings has uncovered failings at a mental health trust.

The review of Sussex Partnership NHS Foundation Trust included the case of Donald Lock, who was stabbed after a collision between two cars in West Sussex in 2015.

The trust has already apologised for its role in the lead up to the death of Mr Lock.

Learning from mistakes

But a new independent review has found the trust did not always learn fully from previous mistakes and sometimes severely underestimated the risk posed by mental health patients.

It also failed to include the views of families, some of whom asked for help, and did not always send people with signs of psychosis to specialist services.

Commissioned by the trust and NHS England, the review analysed previous reports into the 10 killings to see if any lessons could be learned.

A review of 10 killings has uncovered failings at a mental health trust.

The review of Sussex Partnership NHS Foundation Trust included the case of Donald Lock, who was stabbed after a collision between two cars in West Sussex in 2015.

The trust has already apologised for its role in the lead up to the death of Mr Lock.

Learning from mistakes

But a new independent review has found the trust did not always learn fully from previous mistakes and sometimes severely underestimated the risk posed by mental health patients.

It also failed to include the views of families, some of whom asked for help, and did not always send people with signs of psychosis to specialist services.

Commissioned by the trust and NHS England, the review analysed previous reports into the 10 killings to see if any lessons could be learned.

Matthew Daley admitted stabbing Mr Lock to death in July 2015, claiming diminished responsibility, and was convicted of manslaughter in May.

Lewes Crown Court heard Mr Daley had chronic mental health problems and his family had pleaded with the NHS to have him sectioned.

Sussex Partnership has admitted it should have carried out a formal assessment for Mr Daley, who had a diagnosis of Asperger's – but who also had symptoms of psychosis.

Trust to blame

Mr Lock's family has said they believe the NHS trust is to blame, saying he would still be here today if it had done its job properly.

An internal Sussex Partnership report into the care provided to Mr Daley has not been published by the trust. An independent review of the case by NHS England is not expected to be published until next year.

In the new review, investigators found that in seven of the cases, there was criticism of how the NHS trust assessed the risk posed by its patients.

Inadequacies reported

In several cases, the process was reported to be ‘inadequate and the risk posed by the service user went unrecognised or was severely underestimated’.

In some cases, risks assessments were not completed or were completed incorrectly and risk management plans were not completed.

The review said some diagnoses were incorrect and remained unchanged in the face of the service user's behaviour.

Investigators found that assessments were not updated when circumstances changed – such as a new criminal conviction – while some assessments were started but not completed.

A ‘think family’ approach was rarely, if ever, followed and several of the people who went on to kill might have had a dual diagnosis – such as both a mental illness and a substance misuse problem – but this was not identified.

The report said learning after each killing was not always taken up across the trust and there was some repetition in the recommendations made after each one.

Failures to keep up-to-date

Investigators also found that, as recently as December 2015, records were not always updated.

Sussex Partnership chief executive Colm Donaghy said: ‘We commissioned this review with NHS England because we want to make sure we have done everything possible in response to these tragic incidents.

‘We have a responsibility to the patients, families and local communities we serve to ensure this.

‘We have investigated each of the incidents individually. We also wanted independent, expert advice about any common themes which may link them.

‘Sometimes, as is the case across the NHS, we need to improve processes, policies and training in response to incidents involving our services. But that isn't enough on its own.

‘This review sends us a strong message about the need to identify and embed learning when things go wrong in a way that changes clinical practice and behaviour.

‘This goes beyond action plans; it's about organisational culture, values and leadership.’

Marjorie Wallace, chief executive of the mental health charity Sane, said: ‘We are pleased these steps are being taken to deal with the families who have been so often disregarded and who experienced obstacles in finding out the truth.

‘We hope they will be more included in future, but are concerned that even now at least some families have not been involved in this review.’

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