AWP accepts findings of independent investigation reports
Criticism of the care delivered in May 2007 to a man (Mr B) who killed his stepfather has been accepted by Avon and Wiltshire Mental Health Partnership NHS Trust which has apologised for the failings identified.
The criticisms are contained in an independent investigation report published today (16 January) by the Patient and Care Standards Sub Committee of NHS South of England.
In reviewing the care delivered by the Trust almost five years ago, it highlights a number of service failings including:
• Inadequate appreciation of the complexity of Mr B’s care and treatment needs
• A failure to ensure that Mr B’s physical health needs were effectively dealt with
• Poor risk assessment, planning and record keeping
• A failure to listen to and work with relatives
• A failure to recognise the impact of Mr B’s aggressive and intimidating behaviour
The independent investigation team concludes that “at the time of the incident (14 May 2007) the Community Mental Health Team had failed to recognise the levels of risk presented. Consequently Mr B’s significant ongoing treatment and care needs remained largely unrecognised”.
Whilst identifying failures that prevailed in 2007, including taking insufficient notice on the history of physical and sexual abuse within the family, the independent investigation team recognised that both Mr B’s reluctance to disclose the extent to which his Obsessive Compulsive Disorder was impacting on his life and his mother’s tendency to under-report his physical and mental health status gave those trying to support him a misleading picture.
The team also supported the findings and conclusions of the Trust’s own investigations in October 2007: “The recommendations arising from the Trust’s internal serious untoward incident report have resulted in a significant number of service improvement responses for which the Trust should be commended”.
Accepting the report’s conclusions, AWP Chief Executive Laura McMurtrie said: “On behalf of the Trust I would like to offer my sincere apologies to Mr B and his family for the unsatisfactory care provided to them in 2007. Mr B was a challenging person to support but we should have recognised the risks and been more proactive in our support.”
“As the independent investigation team acknowledges, changes have already been made since 2007 to care and discharge planning, carer’s assessments and the involvement of families and carers to inform care and treatment decisions.”
A 23 point action plan has been drawn up to deal with the recommendations of the report and to ensure that current practice does not have the same weaknesses as those identified for the care provided in 2007.
Report into the Care and Treatment provided to Mr Y
A second report published by the SHA related to a homicide in 2007 by a service user who was under the care of Cornwall Partnership NHS Foundation Trust and who had been under our care in Bristol for a seven month period in 2004. He was convicted of manslaughter and also detained under the Mental Health Act.
Commenting on this report Laura said: “Substantial changes have taken place in the Trust since the seven month period in 2004 when Mr Y was under the care of our mental health services.
“Weaknesses in relation to needs assessment, care planning, medication and support provided to Mr Y at that time have been identified in the report and to ensure that these have been fully dealt with in the intervening period, the Trust is implementing a 15 point action plan designed to ensure that all current practices follow best practice.
“On behalf of the Trust I would like to apologise to Mr Y and his family for the standard of care provided and the failure of agencies to grasp the opportunity that existed in 2004 to help Mr Y by providing more effective support.”
Both reports will be published by the SHA later today (16 Jan) and will be available via this link.