An independent inquiry into the care and
treatment of a diagnosed schizophrenic man who strangled his
pregnant girlfriend has urged Wiltshire social services to review
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. Gray was admitted to Broadmoor
hospital and their surviving two children now live with Sivil’s
A number of serious criticisms are made in the
report, commissioned by Wiltshire social services and Wiltshire
health authority, but no single failure of services or professional
care is blamed.
Director of social services at Wiltshire
council, Ray Jones, said that despite a whole range of mental
health services and supervision Gray had received over 14 years, it
was impossible to predict that such an event would occur.
“This is not a story about someone who got
lost in the system. It is an instance where the complexities and
difficulties Gray presented in the end led to a tragedy which we
were unable to prevent,” Jones said.
The report highlights concerns over 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 office dealing
with the case. 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 by
Gray, there was no substance misuse service available locally.
Wiltshire social services was responsible for
his care throughout his contact with adult mental health
The report adds that Avon and Western
Wiltshire Mental Health Care NHS Trust and social services should
review procedures for multi-disciplinary meetings. It concludes
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.