The care of a mental health patient who went on to murder four people was “not entirely satisfactory”, but there were no missed clues about his potential for extreme violence.
That was the verdict of an independent investigation into the care and treatment of Daniel Gonzales, commissioned by South East Coast Strategic Health Authority and Surrey Council, which reported today.
Gonzales, who had schizophrenia, was in the care of mental health services in Surrey from 1997, when he was 17, to 2004.
In September 2004, he attacked an older man with a knife in Southsea, Hampshire, and on the same day killed a woman in Southwick, Brighton.
Two days later he killed three people in north London and seriously injured another. In 2006, he was given six life sentences for the four murders and two attempted murders. In August 2007, he died in Broadmoor Hospital, apparently as a result of suicide, aged 27.
Lucy Scott Moncrieff, the author of the independent report, said: “We were specifically asked to consider whether Mr Gonzales’ extreme violence was predictable and possibly preventable. I think it is important to confirm that we have found nothing to suggest that evidence of Mr Gonzales’ potential for violence was overlooked.”
Not treated successfully
However, she said that, overall, Gonzales was not treated successfully, with evidence that professionals were unable to engage with him effectively.
She said the report’s main recommendation was for engagement with service users to be prioritised.
Fiona Edwards, chief executive of Surrey and Borders NHS Foundation Trust, whose predecessor organisation, North West Surrey Partnership NHS Trust, cared for Gonzales, accepted the conclusions.
She said that since the case, “more robust systems” for dealing with people with similar problems to Gonzales had been introduced.
Witnesses told the inquiry that, before September 2004, Gonzales was “entirely unremarkable in his presentation and the nature of his contacts with services”.
The report said this was an “uncomfortable finding” for people providing services to users with Gonzales’ profile as it “makes clear that something more than improved risk assessment is needed to reduce the likelihood of actions of this kind”.