NHS failed to pass on social worker’s referral about patient who went on to kill

A mental health trust failed to send police a social worker’s request for multi-agency protection of a forensic patient who went on to commit murder, a police watchdog has found.

Oxleas NHS Foundation Trust admitted the error but said an internal review found it was “not considered to have contributed to” attacks carried out by Nicola Edgington that led to one woman’s death. An independent inquiry will be launched into health agencies’ contact in the case, the trust confirmed.

Edgington was jailed for life at the Old Bailey on Monday with a minimum term of 37 years for the murder of Sally Hodkin, 58, and given a concurrent sentence of life with a minimum term of 20 years for the attempted murder of Kerry Clark, 22.

In the hours before the attacks five calls were made to emergency services asking for help for Edgington. Police operators were told that Edgington wanted to be “sectioned” under the Mental Health Act as she feared she “may kill somebody”, an investigation by the Independent Police Complaints Commission (IPCC) found. She was taken to hospital voluntarily by police but walked out approximately 90 minutes before the attacks.

Edgington had been sentenced to an indefinite hospital order in 2006 after being convicted of manslaughter for fatally stabbing her mother. In 2009 she was discharged into the community with conditions, including regular contact with her forensic social worker and a community psychiatric nurse.

IPCC investigators found that agencies had failed to make Edgington subject to multi-agency public protection arrangements (MAPPA) on her release, despite her being eligible. MAPPA is a statutory set of arrangements operated by criminal justice agencies designed to protect the public and prevent re-offending of violent offenders.

Police were not aware of Edgington’s eligibility for MAPPA as they had not been notified by staff at the Bracton centre forensic mental health service where she had been treated prior to discharge in 2009, the IPCC found.

Edgington’s forensic social worker had forwarded a referral intended for the police’s MAPPA representative to the clinical director at the Bracton clinic, but this had not been passed to police, investigators said.

The IPCC said that the reasons behind the NHS’s failure to pass on information were out of the scope of its investigation, which focused on police contact only. A separate independent inquiry is to be held into NHS agencies contact in the case.

Oxleas NHS Foundation Trust, which runs the Bracton centre, attributed the “regrettable” issue to “human error”. The trust’s internal investigation found that the failure to pass on the referral is “not considered to have contributed to the incident”.
 
“Prior to this incident, Ms Edgington had not breached any of the conditions of her conditional discharge and there were no signs of a relapse of her mental illness. Therefore, she would not have been subject to a review by the MAPPA panel,” an Oxleas NHS Foundation Trust spokesperson said.
 
“The clinical director believed she had sent the referral. At the time it was not police practice to acknowledge receipt of referrals and this error was not picked up. As a result of the inquiry, all referrals are now formally acknowledged.”

The investigation by the IPCC into police contact with Edgington prior to the murder of Sally Hodkin found:

• Police failed to carry out a Police National Computer check on Edgington during their interactions with her on the day of the murder, which would have alerted them to her previous conviction for manslaughter
• Officers missed an opportunity to use their powers under section 136 of the Mental Health Act when Edgington tried to leave an A&E department shortly after she arrived with police
• Edgington’s second 999 call from the A&E department was downgraded because she was considered to be in a place of safety and an officer was not asked to return, despite Edgington saying she could be very dangerous

IPCC Commissioner Sarah Green said investigators had also noted that medical staff had decided “not to use their powers under the Mental Health Act 1983 to detain Nicola Edgington” on the basis that she was voluntarily consenting to admission.

“It is to be hoped that both the Metropolitan Police Service and the Oxleas NHS Foundation Trust will learn lessons from this tragic case to improve the handling of high risk individuals such as Nicola Edgington in the future,” said Green.

The IPCC ruled that no police officers or police staff had breached codes of conduct.