Case 1 - JR - Oxfordshire Mental Healthcare NHS Trust


Background and the incident: J was a registered patient of the Abingdon community
mental health team between August 1991 and October 1996.

Although registered (a case file was open in his name ) the only contact he had with mental health services was through his mother who, between 1991 and 1994, saw a member of the team for support and advice on request .

From June 1994 until October 1996 J's mother was seen on a
regular basis by a social work member of the local CMHT. In May 2001 the Trust and
Social Services were made aware that J had been arrested for killing his mother's
partner M with an air rifle on the 24th of May 2001.

The account of the incident given byJ's mother to the internal review team indicated that she and her friend (M) had beenstaying in Abingdon, trying to sort out selling the house. J had come into the bedroomfirst thing in the morning while his mother was making tea, and shot MC at close rangewith the air rifle.


Current position: J was assessed for detention under the mental health act in the police
station and was put on section 3 and bailed to the Oxford Clinic medium secure unit. In
October 2001, Oxford Crown Court found him unfit to plead. He was detained in hospital
(The Oxford Clinic) under Section 5 of the Criminal Procedure Act 1964, this having the
same effect of a section 37/41 of the Mental Health Act 1983. At present J is unfit to
plead and is likely to remain so for some time, therefore the outcome of criminal
proceedings will not be clarified for some while.


Next steps:

Consequently the Trust agreed terms of reference with the SHA for a
detailed internal investigation with an independent chair.
The investigation team submitted its report to the OMHT board and the Oxfordshire Director of Social and Health Care on the 5th of February 2003 and onwards to the SHA.

An action planning day was held on 2nd July to develop a framework for taking forward the recommendations; the SHA was represented at that workshop. The action plan has been consulted on widely and a final version is to be produced by the end of October.

The Trust and the SHA have agreed on a process for monitoring the implementation of the action plan, and this will culminate in two meetings. A first meeting was held on 13th February between the SHA and the Trust.

The session reviewed the current action plan and the progress made with
the implementation of the recommendations. The action plan is available for information.
Given the departure of the current Director of operations, this work will now be overseen
by the Interim Director of Operations.

The Trusts progress between now and the summer
will be monitored via SUI review meeting planned in May 2004 and then a formal review
session in July 2004.
This will be a workshop session, involving all the key stakeholders.

The SHA has advised the Trust that it expects that all recommendations will have been
implemented by the time of the workshop in July2004.

Case 2 – SH – Buckinghamshire Mental Health NHS Trust


Background and the incident:

On 29th June 2002 S presented to the Tindal Centre inAylesbury and was seen by the duty CPN. As a result further contact was to be offered by the Community Mental Health Team. Following that meeting S did not respond to attempts to re-engage her with the service.

On 1st September 2002 at approximately6.00am C, mother of S telephoned 999 to report a domestic incident.
When the police gained entry to the parent's home they found both the mother and father of S dead, andS had sustained severe cuts to her arms and hands. SH was arrested on suspicion of murder and taken to A&E for a medical assessment of her injuries.

S was assessed as requiring non-urgent surgery, so was then taken to Aylesbury Police Station and formally charged with the murder of both parents.

Current position: On 6th June S appeared at Oxford Crown Court. She was found guilty
of two charges of manslaughter on the grounds of diminished responsibility. The Judge
sentenced her to be detained indefinitely in a secure setting.

S is now detained at Marlborough House Medium Secure Unit.


Next steps: TVSHA asked for the Trust to establish an independently chaired review,
this review was undertaken and the recommendations are being implemented.
This
implementation is being monitored jointly by the SHA and Wycombe PCT.

Following on
from the Boards last update the SHA has worked with Wycombe PCT to establish a
short-acting independent panel to scrutinise and endorse the above decisions and that
compliance with the '94 guidance is in place. This work is now in draft and is being
finalised by Wycombe PCT. It is expected to be taken to the Wycombe PCT Board in
April and the SHA Board will also be asked to review the report.

Case 3 – PF – Buckinghamshire Mental Health NHS Trust

Background and the incident: P is a 50 yr old man with a lengthy history of mental
health problems, the first recorded contact being in 1993 after an overdose of
paracetamol.

P spent some time in Hillingdon before moving to the Buckinghamshire
locality.
Reports mention a previous threat to kill made in 1993 when he was living in a
local hostel.
P had been known to local services but full risk assessment had not been
completed or signed.

P also had a history of alcohol abuse and had a diagnosis of
schizophrenia given in January 2002.

At this time he was living with his wife, doing some decorating work, but was experiencing hallucinations. At this time he was being seen by
a CPN.
On 27th January 2002 P has an informal admission to hospital as a result of his
increased hallucinations.
This was resolved at discharge and he was discharged 2nd February 2002.

On 4th May P's wife made contact with the on-call GP, reporting that both
she and P were experiencing auditory hallucinations.

GP advised that additional medication required and did prescribe Haloperidol, for P or his wife to collect.
Anincrease in depot medication was not recommended. On 5th May 2002 P was arrested on suspicion of murdering his neighbour by stabbing on the previous day.

Current position: P was charged with murder at Aylesbury Crown Court on 18th May
2002. He was remanded in custody and is currently detained at HMP Woodhill, in Milton
Keynes. His trial was listed for May 2003 at Kingston -upon- Thames Crown Court. P
was found guilty of murder and has been transferred to HMP Highdown in Surrey.


Next steps: An independently chaired internal review was undertaken and has just been
published. It has been shared with the BMHT board, lead PCT and the SHA. The Trust is
has developed an action plan in order to implement the recommendations from the
review. This is being monitored by the SHA via regular SUI review meetings.

Case 4 – PC – Berkshire Healthcare NHS Trust

This incident took place on 3rd June. P was an inpatient on formal section of MH Act at
Prospect Park allowed leave to see his brother. On return late in the day, he disclosed to
staff that he had killed his girlfriend and dumped the body in Theale.

The police were informed and this was found to be true. P has been remanded to prison and a court case is likely in the next 6 months. An internal review (independently chaired) has been
requested. Shirley Williams, Chair of Bucks. Mental Health Trust is chairing the Internal
Investigation. The Head of Modernisation is meeting the panel chair to review progress
on this review on 2nd March. The process of putting together the panel and it being able
to commence was delayed due to illness, and part of the purpose of the meeting to to
clarify and agree fresh timescales.
[ This will be Connelly and did get published in an odd presentation ... see no. 156 anon ; Connelly

5
Case 5 – WW – Berkshire Healthcare NHS Trust
The Board will be familiar with the WW inquiry. A separate report is being presented to
the Board to update them on this case.
The 3 internal reviews that have been carried out to date (cases 1-3) are thorough and
were independently chaired. They have taken advice from specialists outside the NHS
Trusts involved. The findings and recommendations in them will be sufficient for the
organisations to apply learning now to reduce re-occurrence.

No decisions to proceed to independent inquiry can be made before the legal
proceedings complete. Cases 1 and 4 are still to complete at court, cases 2 and 3 are
now complete. Independent scrutiny of case 2 is now taking place and is being coordinated by Wycombe PCT.

Once that process is complete, Executive approval of the report will be sought.

Because case 3 has been disposed to prison with no mitigation factors no further action is necessary.
The DoH has been notified of each alleged homicide case when they were reported.
They are clear it is the SHA's role (or delegate to PCTs) to plan appropriate action to
learn from such incidents and to manage the communications issues.

Independent Inquiries
Sian Rees from the DH updated the national SHA leads meeting on progress with the
development of new guidance on Independent Inquiries in January. The National Patient
Safety Agency (NPSA) has been testing an approach known as root cause analysis over
recent months.

The feedback has been that such an approach is more helpful than
previous ways of conducting inquiries. The NPSA are now concluding their findings and it
is hoped that the new guidance will be available in the spring. It is expected that the new
guidance will be clearer about what is meant by 'in touch with services', so that
organisations can be clearer about when an inquiry might be necessary.

An event will be held in March to cover this important work.
In conclusion, when dealing with any SUI, making sure that responsible action is taken in
an open way with a willingness to learn and not to apportion blame is a priority. The NHS
Trusts and PCTs in the Thames Valley are showing this willingness to learn and have
dealt with these incidents in a responsible manner.

The board will be updated again in
three months, and are asked to note the policy issues and the TVSHA approach to the
handling of SUIs set out in this report.

Steve Appleton
Head of Modernisation & Planning – Mental Health, Learning Disabilities & Substance Misuse

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