Two London mental health trusts were criticised today for failings in the care of a mentally-ill man who went on to kill two people, one of whom was also a mental health patient.
Separate independent reports into the care of Peter Bryan criticised the level of experience of staff involved in his care, including a social worker, while receiving community services, and the level of supervision he received while a patient at Broadmoor high security hospital.
Killings of Brian Cherry and Richard Loudwell
Bryan killed Brian Cherry while living as an out-patient under the care of East London NHS Foundation Trust in February 2004. While on remand for killing Cherry, he killed Richard Loudwell, a fellow patient, at Broadmoor, which is run by West London Mental Health NHS Trust.
Bryan had been sent to Rampton secure hospital and diagnosed with paranoid psychosis after beating shop assistant Nisha Sheth to death in 1993. But he was released in 2001 after a mental health review tribunal concluded that his illness no longer warranted his detention.
The report into his care by East London found that Cherry’s killing could not have been predicted and was not the result of any individual failing by a member of staff.
‘Unusual form of illness’
It said that Bryan had an unusual type of illness, which allowed him to appear as though he was acting in a normal manner despite being unwell, a finding it stressed was identified with the benefit of hindsight.
However, it said he was being supervised by an “inexperienced social worker” and a general adult psychiatrist who had never previously had responsibility for someone who had killed.
The report said this constituted a “systemic failure” to ensure professionals allocated to care for him had the necessary experience.
Among its recommendations, it called for only sufficiently experienced professionals to look after such individuals in future. It also recommended a greater degree of sharing of information and improved communication across all agencies.
The trust’s chief executive, Dr Robert Dolan, said he accepted the recommendations, and added that the trust had produced an action plan which reflected improvements made over the past five years.
Patients allocated to suitable staff
He said: “The trust has established new systems to ensure that patients with a history of violence are under the care of staff with sufficient experience and training to look after them – the principal recommendation of the inquiry.”
He also said the trust had increased the number of forensic consultant psychiatrists working with community teams from four to 12.
The report into Loudwell’s killing, on Broadmoor’s Luton ward, found a lack of suitable supervision for both men at the time of his killing and said that both should have had increased levels of observation by staff.
The report also called for all patients to have an appropriate care plan in place and for improvements in the way staff concerns about the ward were responded to.
‘Both men were failed’
Peter Cubbon, who became chief executive of West London Mental Health NHS Trust last month, said he accepted the recommendations of the report, and added that the trust had failed both Loudwell and Bryan.
He said that since 2004, the trust had reduced patient numbers on Luton ward from 20 to 12, increased the number of qualified nurses on the ward from half to two-thirds of the workforce and introduced CCTV on the ward.
He added: “We failed on this occasion both to supervise the two men properly and to take sufficient account of Mr Bryan’s risk to others. We also failed to protect Mr Loudwell from being assaulted and I would like to repeat the apology today that the trust has made to his family over this failing.”
Timeline of case
March 1993: Peter Bryan kills 21-year-old Nisha Sheth.
December 1993: Admitted to the Rampton Hospital.
March 1994: Convicted of the manslaughter of Nisha Sheth on the grounds of diminished responsibility and was returned to Rampton Hospital under sections 37 and 41 of the Mental Health Act 1983.
March 2001: Mental health review tribunal rules he can be conditionally discharged from detention provided he takes anti-psychotic medication.
July 2001: Transferred to the John Howard Centre in Hackney for a six-month trial period.
February 2002: Discharged to Riverside House.
6 February, 2004: Allegation that Bryan has indecently assaulted a 17-year-old girl.
10 February, 2004: Admitted as an informal patient to Topaz Ward, the acute adult psychiatric ward at Newham Centre for Mental Health for his own safety.
17 February, 2004: Kills Brian Cherry.
20 February: Remanded to Pentonville Prison.
23 February, 2004: Remanded to Belmarsh Prison.
15 April, 2004: Transferred to Broadmoor Hospital.
25 April, 2004: Attacks Richard Loudwell, who later dies of his injuries.
15 March, 2005: Sentencing hearing at The Old Bailey at which he is given concurrent life sentences to be served at a ‘special hospital’.