Findings are published today of an independent investigation into the circumstances surrounding the care and treatment of Mr K.
Sincerest sympathies are offered to all the people who have been affected by this event. Mr K was charged with murder and pleaded guilty to manslaughter by diminished responsibility of Russell. Mr K had been under the care of Norfolk and Suffolk NHS Foundation Trust (NSFT) since late 2005. He was receiving monthly support from the Trust at the time of the incident.
Dr Lynne Wigens, Chief Nurse at NHS England and NHS Improvement – East of England, said: “We would like to offer our sincere sympathies to the people who have been affected by this tragic incident.
“When these events occur, we work closely with the relevant organisations to ensure that lessons are learned and any necessary improvements are put in place to ensure patient and public safety.”
The independent investigation was commissioned by NHS England following an internal investigation completed by Public Health Suffolk into the events leading up to the death of Russell. Russell died after he was stabbed by Mr K in June 2013.
The aim of this independent investigation is not to investigate the circumstances of the offence, but to enable the providers of care, and the whole of the NHS, to learn lessons and make improvements for the benefit of future patients, their carers and the public. We commission these reports so that the NHS is open and transparent with the families involved and the wider public about what took place and what the NHS is doing to fix it.
The investigation team’s view is that there was a lack of joint working with the agencies involved with Mr K’s care at the time of the incident. There was no discussion with other services when it was decided to change his mental health support in 2012 and there was a lack of detailed assessment of Mr K’s risk of harm to himself and others.
The report found that there were no indicators that a violent act was more likely to occur at the time of the incident. Although Mr K had previously been involved in incidents of violence, his risk of violence to others was historical and there was no recent evidence of any escalation in risk or new factors to increase that risk.
The independent investigation does not consider that Russell’s homicide was predictable by any services Mr K was involved with. It also does not consider the homicide to have been preventable.
The report concludes that there are areas where additional learning can be unlocked for the NHS as a result of this tragic event and has made six recommendations:
- Joint information sharing agreements should be launched with Suffolk Constabulary
- Implementation of action plans in multi-agency investigations should be overseen
- Existing multi-agency investigations Dual Diagnosis guidance should be audited
- NSFT’s improvement programme should be evidenced
- A joint working protocol should be agreed
- An assurance audit of implementation of the action plan should be undertaken