Inquiry finds killer was poorly assessed

There were serious failings in the care and treatment of a paranoid
schizophrenic who killed his ex-partner, a report of the
independent inquiry into his contact with NHS mental health
services finds.

The man, who cannot be named, was primarily under the care of
Cornwall Healthcare Trust, now the Cornwall Partnership Trust. But
a Cornwall social services approved social worker did assess him
under the Mental Health Act 1983 on 13 November 2000, the day
before he killed his ex-partner.

The inquiry panel concluded that, had these assessments been
carried out to an acceptable standard, the man would most likely
have been detained in hospital as there was enough evidence
available to indicate that a serious incident between him and his
ex-partner was likely.

It found a “hands-off” style of senior management, which resulted
in the community mental health team managers and practitioners
being insufficiently supported. Policies had been poorly drafted
and not implemented.

The panel called on the trust and social services to review the
effectiveness of their joint working at all levels. Cornwall social
services must also remind all approved social workers of their
overall responsibility for co-ordinating mental health assessments
of those who may potentially be admitted to hospital under the
Mental Health Act.

Cornwall social services described the report as unbalanced, but
said that it was committed to learning from the events. 

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