Failings In Double Murderer Case

A double murder MAY have been prevented if staff from Tees, Esk & Wear Valleys NHS Foundation Trust hadn't missed the oppertunities to stop it.

It was back in April 2012 that James Allen murdered 81 year old Colin Dunford in his Middlesbrough home.

Two days later the body of 50 year old Julie Davison was found in her flat in Whitby.

Allen was under the care of Tees, Esk & Wear Valleys NHS Foundation Trust so an investigation was launched into his treatment.

The findings, published today are below, Allen is referred to as MR F.

PUBLICATION OF INDEPENDENT INVESTIGATION INTO THE HEALTHCARE AND TREATMENT OF MR F

Findings are published today of an independent investigation into the healthcare and treatment of Mr F.

On 23 April 2012, the first victim was found dead in their home having sustained significant facial and head injuries. On 25 April 2012, a second victim died from head and neck injuries.

Following his arrest on 29 April 2012, Mr F was found guilty of both murders and received two life sentences with a minimum term of 37 years.

At the time of the offences, Mr F was receiving care from Tees, Esk and Wear Valleys NHS Foundation Trust, provider of mental health services.

Following completion of legal proceedings, NHS England commissioned Niche Patient Safety to conduct an independent investigation into the healthcare and treatment provided to Mr F, to see if there were lessons to be learned by all agencies involved in his care.

On predictability and preventability, the investigation panel concluded that:

Predictability

“…there was enough evidence to indicate that Mr F was a vulnerable individual who had significant known risk factors. Therefore, it was Niche’s opinion that services should have identified that there was a significant probability that he would reoffend. What was not predictable was Mr F’s choice of victims in this tragic double homicide.”

Preventability

Niche Patient Safety concluded that it was more difficult to definitely determine whether the incident was preventable.

“Mr F was a serial offender who was either unwilling or unable to engage in any meaningful rehabilitation programme. The evidence indicates that there were many deficiencies and missed opportunities by both primary and secondary health care services where important information could have been sought and shared. If obtained, this information would have enabled a more accurate assessment of Mr F’s risk factors and would have alerted agencies to his potential for reoffending.”

Main findings

1. Mr F was registered with two primary care services and attended a walk-in centre on several occasions. Neither surgery 1 nor the walk-in centre was able to access surgery 2’s patient records.

2. It took a considerable amount of time for surgery 2 to identify that they were over-prescribing Pregablin (the drug prescribed to treat Mr F’s neuropathic pain) and that it was likely he was misusing this medication.

3. No mental health agency sought to obtain information regarding Mr F’s forensic history from the police or probation service.

4. As the prison service does not release a prisoner’s medical notes on release, primary care services were unaware of Mr F’s full history.

5. Despite Mr F repeatedly reporting his fears of a relapse in his mental health, there was no evidence of a risk or relapse management plan being identified. No agency considered the potential psychological effect of Mr F’s chronic health condition on his mental health.

Recommendations

Niche Patient Safety made 10 recommendations for action and implementation by both primary and secondary care services:

1. Both primary and secondary health care clinicians should undertake domestic violence training in order to improve both their understanding of and their responsibilities for reporting suspected and known incidents of domestic violence.

2. When a patient is identified as having a history of offences, the crisis and affective disorder teams must, as a matter of course, seek to obtain information from the police and probation services.

3. The trust should review its current safeguarding policies to ensure that they reflect the findings of the latest HMIC report Everyone’s business: Improving the police response to domestic abuse and Cleveland Police’s associated action plan (2014).

4. Mental health services’ risk assessments and support plans should be identifying and considering a patient’s current housing situation. Where a patient is experiencing housing issues, this should be identified as both a significant risk factor and one that requires support.

5. When a patient is registered with two primary health care services, there needs to be improved communication and information sharing between the practices.

6. Secondary mental health care services should be aware that patients on a methadone programme in this area may be registered with two primary care services. If this is the case, they must ensure that communication is being sent to both services.

7. Both primary and secondary health care services should be considering the possible psychological effects and the potential for misuse of prescribed medication in patients with chronic or on-going physical health issues. This issue should be considered within mental health risk and care planning.

8. NHS England’s regional homicide leads need to address the lack of information sharing by prisons’ medical services.

9. Primary care services should consult with the prescribing mental health clinician when they are considering changing a patient’s psychiatric medication.

10. The trust and authors of the post-incident review report (PIR) should make every effort to obtain access to primary care notes and interview the relevant GPs. Where the perpetrator is known to have a forensic history, they should also obtain probation service and police information.

The panel’s findings will be used by local clinical commissioning groups, who have responsibility for purchasing mental health services for local people, in order to inform future commissioning criteria and decisions.

Commenting on the report Karen Conway, head of investigations for NHS England North, said:

“The circumstances surrounding the tragic death of these two victims are extremely upsetting and our deepest sympathies go to their family and friends.

It is clear that the care provided to Mr F could and should have been better and fell well below expected standards. The report rightly highlights a number of issues around roles, responsibilities and working practices which must be resolved for positive progress to be made.

As commissioners of GP services in the region, we will be ensuring that all recommendations relating to primary care are implemented and embedded into general practice.

The mental health trust needs to scrutinise fully the areas highlighted for improvement to make sure all the recommendations are implemented, and that positive progress is clearly demonstrated.”