Inquiry urges Wiltshire to review procedures

An independent inquiry into the care and treatment of a man with
schizophrenia, who strangled his pregnant girlfriend, has urged
Wiltshire social services to review its current policy and
procedures, writes Clare Jerrom.

Richard Gray attacked Ginny Sivil while she was in the early
stages of labour with his child. Both Sivil and the unborn baby
were killed in the attack. Gray was admitted to Broadmoor hospital
and their surviving two children now live with Sivil’s
parents.

A number of serious criticisms are made in the report,
commissioned by Wiltshire social services and health authority, but
no single failure of services or professional care is blamed.

Ray Jones, director of social services at Wiltshire council,
said that despite the whole range of mental health services and
supervision Gray received over 14 years, it was not possible to
anticipate the tragedy which occurred.

“This is not a story about someone who got lost in the system.
It is an instance where the complexities and difficulties Mr Gray
presented in the end led to a tragedy which we were unable to
prevent,” Jones said.

The concerns highlighted in the report are about the care of
conditionally discharged patients within local psychiatric teams
and multi-disciplinary communication.

“Key information concerning Richard Gray’s thoughts of
killing Ginny Sivil and his family did not become known to all
professionals involved and did not reach the home office. This was
despite many opportunities for multi-disciplinary exchange of
information,” the report says.

There was no planned or co-ordinated arrangement for risk
assessment and despite regular drug use featuring in Gray’s
life throughout his conditional discharge, there was no substance
misuse service available locally to advise on the problem.

Wiltshire social services were responsible for his care
throughout his contact with adult mental health services. Over the
years he voiced thoughts of killing his family, but the home office
were not informed.

According to recommendations made in the report, the home office
should consider reviewing their guidance on: the legal framework
within which social supervision may be provided by social services
and probation, the desirability of developing local joint policies
between probation and social services and the importance of
explaining the purpose of conditional discharge clearly to
patients.

Social services should also develop forensic training for staff
working with higher risk clients.

Avon and Western Wiltshire Mental Health Care NHS Trust and
social services should review procedures for multi-disciplinary
meetings. In addition, there should be a joint procedure for the
assessment and management of risk and any named person thought to
be at risk from a patient should be informed, it concludes.

Jones said: “We have accepted all the recommendations in the
report, but most importantly in Wiltshire, we have put in place,
since April, an integrated health and social care mental health
service which should reduce the boundaries and difficulties between
staff working within one area and should improve in the future, the
exchange of information, case planning and co-ordinated
action.”