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Sussex NHS mental health trust killings 'predictable' Sussex NHS mental health trust criticised over killings by patients
(about 2 hours later)
Two killings committed by patients under the care of a mental health trust were predictable and could have been avoided, a report has said. A mental health trust underestimated the risk posed by its patients and sometimes did not act on threats to kill, a review of 10 killings over eight years has found.
A review looked into 10 deaths linked to Sussex NHS Partnership Foundation Trust patients. The review examined deaths linked to Sussex NHS Partnership Foundation Trust patients between 2007 and 2015.
It found killings by Kayden Smith in 2012 and Roger Goswell in 2007 were "preventable" and "predictable". It found killings by Kayden Smith in 2012 and Roger Goswell in 2007 had been "preventable" and "predictable".
The review was launched following the stabbing to death of Donald Lock, 79, by Matthew Daley in 2015. The trust has apologised and offered its condolences to families.
Daley, who was under the care of the trust at the time, was convicted of manslaughter on the grounds of diminished responsibility after stabbing Mr Lock 39 times following a collision between two cars on the A24 in Findon, West Sussex. Two families' stories
During the trial, jurors were told Daley's mother pleaded with mental health experts to have her son sectioned. The review of what is one of England's largest mental health trusts was launched following the stabbing to death of Donald Lock, 79, by Matthew Daley in 2015.
The review looked at nine killings between 2007 and 2015 committed by patients of the trust and one who was killed while under the care of the trust. Mother's plea
Smith killed Danish tourist Jan Jansen at his flat in Hassocks in 2012 while Goswell, who was also a patient, killed his wife Susan in West Chiltington in 2007 before taking his own life. Daley, who had been under the care of the trust at the time, was convicted of manslaughter on the grounds of diminished responsibility after stabbing Mr Lock 39 times following a collision between two cars on the A24 in Findon, West Sussex.
The independent review commissioned by the trust and NHS England found that, in several cases, the process to assess patients was said to be "inadequate" and "the risk posed by the service user went unrecognised or was severely underestimated". During the trial, jurors were told Daley's mother had pleaded with mental health experts to have her son sectioned.
The review looked at nine killings committed by patients of the trust and the case of one patient who was killed while under the care of the trust.
Smith killed Danish tourist Jan Jansen at his flat in Hassocks, while Goswell, who was also a patient, killed his wife Susan in West Chiltington before taking his own life.
The independent review commissioned by the trust and NHS England found that, in several cases, the process to assess patients was "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".In some cases, "risks assessments were not completed or were completed incorrectly".
The report said: "Some diagnoses are incorrect and remained unchanged in the face of the service user's behaviour.The report said: "Some diagnoses are incorrect and remained unchanged in the face of the service user's behaviour.
"Sometimes service users made threats to kill others but no further action, for example informing the police or warning the person threatened, was taken.""Sometimes service users made threats to kill others but no further action, for example informing the police or warning the person threatened, was taken."
It added: "If the service user had been assessed as high risk then a management plan would have been triggered." It added: "If the service user had been assessed as high risk, then a management plan would have been triggered."
The report said learning after each killing had not always been taken up across the trust and there was some "repetition" in the recommendations made after each one.
Ten cases reviewedTen cases reviewed
Colm Donaghy, chief executive of the trust, offered his "sincere apology and condolences" to families.Colm Donaghy, chief executive of the trust, offered his "sincere apology and condolences" to families.
He said: "I realise this may bring back painful memories for them. I also understand that some, if not all, will feel angry about our services. Mr Donaghy said the trust had commissioned the review with NHS England because it wanted to make sure "we have done everything possible in response to these tragic incidents"
"I realise this may bring back painful memories for [the families]. I also understand that some, if not all, will feel angry about our services," he said.
'Strong message'
"We have investigated each of the incidents individually. We also wanted independent, expert advice about any common themes which may link them.""We have investigated each of the incidents individually. We also wanted independent, expert advice about any common themes which may link them."
He added: "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."
Marjorie Wallace, chief executive of the mental health charity Sane, said: "We are pleased that 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."Marjorie Wallace, chief executive of the mental health charity Sane, said: "We are pleased that 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."
Comparison with national figuresComparison with national figures
The 10 Sussex NHS Partnership Foundation homicides were:The 10 Sussex NHS Partnership Foundation homicides were: