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Staff at Prospect Park hospital knew a mentally ill man wanted to attack his girlfriend before he killed her but did not warn her, a new report has revealed. Peter Connelly was also using drink and drugs at the hospital less than a month after it opened and just before he strangled Alison Gable in a Theale garage last year.
Connelly, who had been sectioned under the Mental Health Act with a psychopathic personality disorder, killed her while on two weeks leave from Prospect Park in June 2003. Staff knew he had "thoughts of harming his girlfriend" but did not warn her or her own health carers, a report from the Reading Primary Care Trust said. Connelly, 26, admitted manslaughter on the grounds of diminished responsibility and is serving a life sentence.
The report given to Thames Valley Strategic Health Authority (TVSHA) uncovered the failures of the Berkshire NHS Healthcare Trust, which runs Prospect Park in Honey End Lane, Tilehurst, but has not ordered a public inquiry.
It concluded recommendations would be enough to stop a repeat of the tragedy.
Connelly and Mrs Gable had first met at Fair Mile Hospital in Cholsey. Connelly transferred to the newly opened £24 million Prospect Park Hospital in May last year when the old Victorian psychiatric hospital closed down while Mrs Gable, 37, went to live with her parents.
When Connelly was given his leave, he told hospital staff he intended to find work, but instead he went to see Mrs Gable at her home in Roundhead Road, Theale, and killed her.
Connelly returned to Prospect Park Hospital after the killing and confessed to hospital staff. Berkshire NHS Healthcare Trust held an internal review into what it called the "serious untoward incident".
It was followed by an independently chaired review and an external assessment carried out by Reading Primary Care Trust (PCT).
The Thames Valley Strategic Health Authority has decided it will monitor the action of the Berkshire NHS Healthcare Trust to ensure it carries out proposals arising from the review.
The detailed recommendations of the first review have not been made public.
However in the report to the TVSHA, new recommendations include better risk assessment training for Prospect Park staff. S
taff will also be told when they should warn people about threats from patients. Reading Primary Care Trust found "that it was made clear by Mr PC [Connelly] over many weeks that he had thoughts of harming his girlfriend".
The PCT felt "the services did not take these threats seriously enough particularly on the first occasion when staff relied upon Mr PC to inform Ms AG that he had thoughts of killing her".
The PCT found that, despite patient confidentiality, information should at the very least have been passed on to the team caring for Mrs Gable.
Berkshire NHS Healthcare Trust also reviewed its policy on drug and alcohol misuse on wards and provided guidance to staff to make it clear if and when the police should become involved.
It must also review the clinical practice of Dr S – not named in the report – in connection with assessment, treatment and the granting of section 17 leave from hospital to mentally ill patients.
In deciding whether to hold a public inquiry, the TVSHA had to decide if it would be in the public interest, whether media or political interest calls for an inquiry and had to take into account whether the family of the victim has called for one.
Steve Appleton, head of modernising and planning at TVSHA, said a public inquiry would not be in the public interest as the findings and recommendations contained in the report will be sufficient for Berkshire Healthcare Trust to implement training to reduce the likelihood of another such incident.
Review into the PC case in Berkshire
The Director of Modernisation and Planning provided [ to the TVSHA Board ] the background to this case and advised that following the independent review presented to the Board in June it was agreed that an external assessor be asked to review the report to advise on the robustness of the independent review and whether they considered a public inquiry to be necessary.
Mrs Lynda Wincombe was asked to undertake this work and reported that in her opinion the report was well written, well balanced and identified most issues.
She felt there were a couple of weaknesses within the areas of substance misuse and the Mental Health Act which she had raised within her recommendations.
The methodology of the internal review, by using external professionals, was good.
Recommendations should perhaps have been more specific but had taken account of all issues.
She advised that she had been unable to locate the Terms of Reference for the internal review panel so it was difficult to know if objectives were met.
Her judgement was that overall the internal review was robust and that there was no requirement for a full independent enquiry.
Mr Ken Dixon, Non-executive Director indicated that it was good to receive this report demonstrating in public the competency of the scrutiny of this process. For the record, the Chairman advised of the previous experience of Mr Dixon in dealing with matters of this nature.
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