User received ‘misguided care’ before he killed grandfather

Professionals missed six opportunities to assess a patient under the Mental Health Act (MHA) and provided him with ‘misguided care’ in the three months before he killed his grandfather, a review has concluded.

Though William Barnard’s killing of grandfather John McGrath on 24 July 2009 could not have been predicted, there were sufficient indicators between 20 April and 19 July of that year for the assertive outreach team responsible for his care to assess him under the Act.

Had he been sectioned the killing would have been prevented, though there was no guarantee that this would have followed from an assessment, said the independent investigation into Nottinghamshire Healthcare NHS Trust’s care of Barnard.

However, the review, commissioned by NHS East Midlands, concluded: “What an assessment would have provided was a clear and detailed analysis of [Barnard’s] mental state and the opportunity to have re-engaged him in a treatment plan, or to have made clear to him the consequences, to him, of not re-engaging in treatment.

“It is this lack of assessment, and the loss of opportunity to have assessed his mental state in advance of the incident, that continues to generate anger and distress for his family.”

Barnard, who had a diagnosis of paranoid schizophrenia and a methadone addiction, had been in contact with adult mental health services in Nottinghamshire since 2002 and had a history of disengagement with services.

The review concluded that his care had been good from 2002-7 and reasonable from 2007 to April 2009, but then became “misguided”.

A MHA assessment had been organised for 9 April but did not take place because Barnard was not in at the time when professionals visited his home.

The review found that the subsequent missed opportunities arose from the assertive outreach team lacking a complete picture of Barnard’s past risk behaviours, failing to respond assertively to early warning signs, such as verbal aggression, and not following through on its own plan to attempt a subsequent assessment of Barnard after six weeks.

It also identified a lack of effective team leadership and of access to medical support, saying that the number of funded psychiatric sessions for the assertive outreach team was insufficient for its caseload. The level of communication between the team and the dual diagnosis service was “unacceptably low”.

However, it also found that the team was carrying high caseloads and that workloads had risen rapidly following a reorganisation to align its boundaries with the local authority.

The review made five recommendations, including for the assertive outreach team to receive more medical support and to carry out a caseload audit to identify how far relevant historical risk factors are taken account of in risk assessments, and for the trust to consider more training in the requesting and organisation of MHA assessments.

“We have no way of knowing whether an assessment by the assertive outreach team would have resulted in an admission to hospital, however there were clear signs that an assessment should have been made, if only to inform staff about William’s state of mind,” said the trust’s medical director, Peter Miller. “The report agrees with the decision to make a planned assessment, but there then followed an unacceptable lapse in the process. For this I apologise sincerely.”

He said all five recommendations had been fully implemented with improved training on MHA assessments, increased medical support for the assertive outreach team and improved links between it and other teams.

Barnard was found guilty of manslaughter and is now detained at Rampton high security hospital in Nottinghamshire.

The independent investigation was carried out by Consequence UK Ltd.

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