Suffolk: Nine killings by people known to county’s mental health services
SUFFOLK’S mental health trust has released a shocking report of its failings following nine killings in less than two years.
The action taken following the killings – all carried out by those who have at one time had services offered under the Suffolk Mental Health Partnership Trust – has been criticised in the independent review, which has led to many high level changes in the Trust.
Among the victims of the killings, which took place between May 2009 and February 2011, was Bury mum of three Mary Griffiths, who was brutally murdered in front of her children by John McFarlane. It emerged that McFarlane had contact with the Trust after he attempted to take his own life just days before the murder but had not been detained under the mental health act.
The report raises several concerns, including;
- Poor nursing leadership and development
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- Badly kept health records
- Low morale among staff
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- Concerns over governance issues
- Patients with multiple problems dealt with inappropriately
- Medical accountability and working practices are unsatisfactory
- Poor risk assessment
Some of the other people who have allegedly carried out the nine killings and previously received care under the Trust include Lorraine Thorpe from Ipswich (who is serving time for killing Rosalyn Hunt and Des Thorpe), Darren Weatherley from Needham (who admitted manslaughter after killing his mother), and Rodney Greenland (who is in prison for the murder of Simon Amers). The others cannot be named as the cases are ongoing.
Since the report, many changes identified in a new action plan have been implemented and the new chief executive Aidan Thomas, who joined from Norfolk’s Trust in March ahead of its merger with Suffolk, has said he is confident lessons have been learned from the tragic incidents.
Mr Thomas said: “In every case you can find there are things you could have done differently and if done differently, the person would still be alive.
“However even if you implement all these things, you cannot promise there will not be another outcome but the chances of it happening are diminished.”
In the report, written by an independent team, there are some damning comments regarding the way the Trust operated at the time of these killings.
It states: “There is no single office in the Trust which retains responsibility for investigating and following through on the homicides [this phrase is used to describe killings]. As a result everyone inside and outside the Trust do not know exactly how many have occurred, and there is no understanding within the Trust of the implications from the homicides. Learning has not been disseminated.”
In another section, it mentions the time and focus on submitting Foundation Trust status bids (which later failed) placed a “strain on the Trust board”
It added that in the west of the county, specific consultant medical staff, were not fully committed to new ways of working or provide the necessary leadership.
Mr Thomas said: “We made the decision to publish this report because we believe it is the right thing to do.
“The future of the Trust will have a much more open ethos, more out-ward looking and responsive. I want staff to feel confident that we will learn from incidents and near misses.”
Barbara McLean, new director of nursing, said the problem was nurses within the management team no longer had contact with patients and this has now been changed.
Dr Dan Poulter, a hospital doctor who is MP for Central Suffolk and North Ipswich, said: “The Trust has accepted there are a lot of things that needed to be put right. What happened was the focus was on St Clement’s and not with working with people in the community. These very tragic events have helped facilitate a re-think into how services are going to be delivered.
“In my discussions with the chief executive, that focus is back on working with people in the community. Lessons have been learned.”
The report was commissioned following the action taken after the nine killings, a series of Serious Incidents Requiring Investigation (SIRIs), and a suicide of a 19-year-old man in Wedgwood House in West Suffolk Hospital, Bury St Edmunds on August 2010.
NHS Suffolk, which called for the review along with the former chief executive Mark Halladay, welcomed the findings and said it will support and monitor the Trust through the improvements.
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