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Publication of independent investigation report into the care and treatment of Tom in Cambridgeshire

Findings are published today of an independent investigation into the circumstances surrounding the care and treatment of Tom.

Sincerest sympathies are offered to all the people who have been affected by this tragic event. Tom was charged and convicted of the manslaughter by diminished responsibility of his wife Sally. He had a long and complex mental health history and had previously had contact with mental health services at Northamptonshire Healthcare NHS Foundation Trust and was in contact with Cambridgeshire and Peterborough NHS Foundation Trust at the time of the incident.

Dr David Levy, Medical Director at NHS England – Midlands and East said: “We would like to offer our sincere sympathies to the people who have been affected by this tragic incident.

“Thankfully, events such as this are rare. However, when they do 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 internal investigations completed by Northamptonshire Healthcare NHS Foundation Trust and Cambridgeshire and Peterborough NHS Foundation Trust into the events leading up to the death of Sally. This investigation was conducted in partnership with the Domestic Homicide Review into the death of Sally, which was commissioned by Huntingdonshire Community Safety Partnership.

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 careers 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 contrast between the mental health treatment Tom received from Northamptonshire Healthcare NHS Foundation Trust and Cambridgeshire and Peterborough NHS Foundation Trust.

In conducting their investigation, the team found that the care provided by Northamptonshire Healthcare NHS Foundation Trust was well managed and consistent. Tom did not engage well with Cambridgeshire and Peterborough NHS Foundation Trust services and did not comply with treatment offered, which suggests Cambridgeshire and Peterborough NHS Foundation Trust should have taken a proactive long-term view rather than focusing on short term management.

With Tom’s history of non-compliance with medication and lack of engagement with on-going care, CPFT should have triggered a more detailed discussion and treatment options. There was however, no history of violence to others, and no suggestion of any violence towards his wife prior to the homicide.

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 seven recommendations:

  1. Handover, transfers of care and discharge
  2. Sharing routes of access to mental health services
  3. Health records policy
  4. Mental health patient notes review standards
  5. Discharge process
  6. Risk policy implementation
  7. Risk management training

View a copy of the full independent investigation report.