Stretched staffing contributed to failings in the care of a mental health patient, who later went on to kill his mother, a review found today.
Jarvis Ford, then 48, stabbed his 84-year-old mother Margaret with a knife at their home in Pembrokeshire, Wales, in May 2009, and was detained indefinitely under the Mental Health Act 1989 after pleading guilty to manslaughter.
In a review into Ford’s care, Healthcare Inspectorate Wales (HIW) said that, although the killing could not have been predicted, there were shortcomings in the care and treatment Ford received from mental health services in Pembrokeshire.
Many of these were due to resource shortages in the Narberth patch community mental health team, which was responsible for Ford’s care after he and his mother moved to the area from Solihull in 2007.
Its social worker was on long-term sick leave and the inspectorate concluded that it was too small to cover the geographical area it was assigned.
It found that Ford’s initial care plan lacked a clear risk assessment based on his clinical history, leading to an inadequate crisis and contingency plan for dealing with a relapse in his condition. Ford had a history of mental illness and had his first psychiatric hospital admission in 1985.
The report also found that the arrangements for the transfer of his care from Birmingham and Solihull Mental Health NHS Trust to Pembrokeshire were inadequate. Other findings included the fact that insufficient regard was given to Margaret Ford’s role as a carer for her son or her own need for care as a vulnerable adult.
Carers and family members also had to engage in a frustrating and cumbersome process to contact social care and NHS practitioners, while processes for accessing emergency mental health assessment and care in the area were inadequate and burdensome, the report added.
HIW chief executive Dr Peter Higson said: “This is a tragic case but it is important to stress that incidents like this are extremely rare.”
At the time of the killing, the then Hywel Dda NHS Trust was responsible for providing mental health services in Pembrokeshire, along with Pembrokeshire Council, but since the trust’s abolition in October 2009, its responsibilities have passed to the Hywel Dda Health Board.
Responding to the report, health board chief executive Trevor Purt said action has already been taken to address the failings identified in the HIW report and an action plan produced. He said staff resource issues had been addressed and an extra mental health practitioner appointed to cover the area in question.
Purt apologised to Margaret Ford’s family but said that the report made clear that the actions of staff were “reasonable” under the circumstances.
HIW said it would review the board’s plans against its recommendations.
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