Publication of an Independent Investigation into the care and treatment of a person using the services of Nottinghamshire Healthcare NHS Trust
The publication of today’s report follows an incident in July 2009 in which a mental health service user (MHSU) killed a family relation and wounded another. In June 2010 the MHSU pleaded guilty to manslaughter on grounds of diminished responsibility and wounding with intent.
At the time of the homicide the MHSU had been receiving specialist mental health treatment from Nottinghamshire Healthcare NHS Trust. Following the incident the Trust conducted an internal investigation, which was reviewed by NHS East Midlands (now part of NHS Midlands and East). Subsequently, and in line with Department of Health guidance, an independent investigation was commissioned.
The investigation was carried out by Consequence UK, an independent agency specialising in conducting such work.
The purpose of the investigation was to examine the care and treatment provided to the individual by mental health services to identify whether different management of his case could have averted the incident, and if any improvements could be made to services to help prevent a similar incident in the future.
By publishing investigations NHS Midlands and East aims to ensure:
- The family has the fullest possible picture of the events and decisions leading up to the incident;
- The wider health and social care economy can consider the findings and make improvements in services; and,
- The public has confidence in the investigation process and that the NHS will act upon the report’s recommendations.
Chris Welsh, Medical Director at NHS Midlands and East, said:
“I would first like to offer my sincere condolences and sympathy to the families affected by this tragic incident. I know that nothing I can say today will make up for the loss of a loved one; the harm done and the heartache that those families experienced and continue to suffer. I hope that in some small way the publication of this report will help provide a better understanding for them and the wider community of the events that took place."
The independent investigation concludes that the MHSU did not have a history of violence or aggression to the extent that one would reasonably have considered him of any significant risk of harm to others.
However it concluded that had he been assessed under the Mental Health Act prior to 24th July 2009 and admitted to hospital on a compulsory basis then the incident would have been avoided.
The investigation could not determine retrospectively that had a Mental Health Act assessment been achieved it would have resulted in the compulsory treatment of the mental health service user. What the Mental Health Act assessment would have provided, though, was a clear and detailed analysis of his mental state and opportunity to re-engage him in a treatment plan.
The investigation makes a number of recommendations for how services could be improved. Nottinghamshire Healthcare NHS Trust has already taken action in response to these. The actions for the Trust continue to be scrutinised by NHS Midlands and East, in conjunction with NHS Nottingham City and NHS Nottinghamshire County, the commissioners of the service.
Notes to Editors
The full report is available at: www.eastmidlands.nhs.uk/about-us/publications/indinvmh/published-independent-investigations/
For further information contact:
David Woodthorpe, Deputy Director of Communications, NHS Midlands and East: 0115 9684491
Anonymisation in Independent Investigations
Independent investigations are conducted by independent experts who are commissioned by NHS Midlands and East (which includes NHS East Midlands). The process includes examining the service user’s clinical records, interviews with relevant staff (including those from other agencies where appropriate) and reviewing relevant local and national policies, procedures and guidelines. It also involves talking directly to those involved in the incident which includes service users, their families and where appropriate families of those harmed. The purpose of the investigation is not to apportion blame but is instead to learn important health system wide lessons.
The completed investigation may contain detailed reports of the clinical care and treatment the service user received and may therefore be subject to the Data Protection Act 1998 and if made public could also breach the Human Rights Act.
As a result we anonymise the identities of victims, perpetrators and staff in the investigation reports. This approach is underpinned by legal advice NHS Midlands and East has received in relation to the requirements of the Data Protection Act 1998 and the Human Rights Act.
NHS East Midlands is part of the NHS Midlands and East cluster of SHAs comprising NHS East Midlands, NHS East of England and NHS West Midlands.
NHS East Midlands provides strategic leadership to NHS organisations in Derbyshire, Leicestershire, Lincolnshire, Northamptonshire, Milton Keynes, Nottinghamshire and Rutland.
The role of NHS East Midlands is to ensure that local health systems operate effectively and efficiently and that national standards and priorities are met in order to continually improve services for patients.
The organisation works in partnership with local NHS trusts, regional government and other partners. NHS East Midlands is ultimately accountable to the Secretary of State for Health.