The murder of a mental health service user “could have been avoided” if a mental health tribunal had received more information about the risks of his killer, a safeguarding adults review has said.
Kamil Ahmad, an asylum seeker diagnosed with post traumatic stress disorder and obsessive compulsive disorder, was killed by one of his neighbours, Mr X, in 2016 at the supported accommodation run by Milestones Trust where they both lived.
This was shortly after Mr X, diagnosed with schizophrenia, was discharged from Kewstoke Hospital, Weston-super-Mare, run by private provider Cygnet Health Care.
The review heard how the patient was released from hospital by a mental health tribunal, contrary to the advice of the hospital psychiatrist and without considering the views of Mr X’s brother, the community psychiatric consultant, or Milestones Trust.
It also said staff at Milestones Trust acted too slowly to terminate Mr X’s tenancy, after Ahmad was subjected to numerous “racially motivated attacks” by his neighbour.
The first incident between the two men occurred in October 2013 when Mr X repeatedly punched his neighbour in the communal area. The police recorded this as a racially aggravated assault but decided against cautioning Mr X – accepting that his mental health had contributed to his behaviour.
Despite being issued a written warning about his behaviour, Mr X attacked Ahmad two months later, leading to his arrest and detention under the Mental Health Act (MHA).
While in hospital, Milestones Trust approached the courts for an injunction to prevent his return to the site. Yet this was rejected as Mr X did not attend court, leaving Milestones to issue him a final warning.
A safeguarding meeting took place between Milestones Trust, police, Bristol council and the care co-ordinator in January 2014 to discuss how Mr X and Ahmad could be safely managed at the property.
Mr X was reminded he was on his final warning and that any further breach would lead to his eviction. Meanwhile Ahmad was offered alternative accommodation but rejected this as it was too far away from his support networks.
Two years later, a safeguarding referral was made as Milestones Trust was concerned about Mr X’s “threatening behaviour” towards Ahmad. When the referral failed to identify incidents of abuse as hate crimes, Ahmad went to the police and complained Mr X had been harassing him.
When the case was investigated by police two weeks later, the Milestones Trust said Mr X had received a final warning and Ahmad was planning to move out. However, the report states this information was incorrect.
Bristol council adult social care department contacted Ahmad on 5 May 2016, almost a month after the safeguarding referral was opened. After offering him alternative accommodation for a second time, which he refused, the safeguarding referral was closed. The report said Ahmad “was not a vulnerable adult” and was “in the process of being discharged from social services”.
Earlier that month, Mr X had refused to take his medication, causing concern about changes in his behaviour. A support worker reported Mr X talking about “murder”, but no further action was taken.
On 10 June, staff at Milestones Trust found notes from Mr X which detailed thoughts to kill other tenants, including Ahmad. This led to the arrest of Mr X three days later on suspicion of threats to kill and indecent exposure. Mr X was later assessed by the mental health team while in custody and detained under the MHA for a second time, though there was a delay to the Mental Health Act assessment due to a lack of beds.
Mr X was initially placed in an Avon and Wiltshire Mental Health Partnership (AWP) NHS
Trust hospital. But Mr X was placed in Kewstoke Hospital, due to capacity pressures in AWP provision.
According to the review, the hospital “did not receive historical information regarding previous concerns about Mr X’s psychiatric history” from AWP, and “only became aware of the extent and significance of the deficits in their records during the mental health tribunal”. This took place after Mr X asked for a review of his detention.
The tribunal was not satisfied that Mr X was “suffering a mental disorder of a nature or degree which warranted his continued detention” and was discharged. This decision was made without considering the views of the community psychiatric consultant or Milestones Trust, and was contrary to the advice of the psychiatrist caring for Mr X in hospital.
Panic at return
Despite efforts to encourage Mr X to remain in hospital as a voluntary patient, the care co-ordinator informed Milestones Trust that he was free to leave hospital and could return to his accommodation.
The Milestones Trust was not informed of the timing of Mr X’s discharge from hospital until an hour before it happened and was unhappy about the lack of consultation. Contingency plans were rapidly put in place to advise female tenants of his potential return and alert the on-call manager. However, Ahmad was not warned about Mr X’s possible return.
After consuming “a litre of rum” and telling the AWP crisis team he “felt like punching an Asian resident” at his accommodation, Mr X murdered Ahmad, and later phoned the police to confess.
He was convicted in October 2017 and jailed for life.
The review concluded the fatal assault on Ahmad “could have been avoided”, stating the decision to discharge Mr X by the mental health tribunal was “based on incomplete information”.
It said the decision to release Mr X “reduced the time available” for the AWP to seek alternative accommodation and for Milestones Trust to commence eviction.
The decision to go against the recommendations of people involved with Mr X was also highlighted in the review. It said the tribunal “did not appreciate the significance of the problems in the accommodation and the inherent risk of Mr X’s return”.
Finally, it added Milestones Trust was “slow to act in pursuing the termination of Mr X’s tenancy” and needed the support of other agencies to achieve it.
It also asked why Mr X was issued “several warnings” about his behaviour and claimed the continued sharing of the accommodation was “clearly detrimental” to both men.
Policy revision needed
The review made 16 recommendations in total, with the Bristol Safeguarding Adult Board (BSAB) advised it should “refresh and re-launch its adult safeguarding escalation policy” for all partner agencies.
The board was told it should “arrange an audit of safeguarding alerts, referrals and responses” to understand how the vulnerabilities of asylum seekers are explored and addressed.
Hospitals and community mental health teams were reminded of their joint responsibility to discharge patients, and the review added the AWP bed availability policy should be revised “to avoid mentally ill people in crisis remaining in the community where they are a risk to themselves and others”.
In response to the review, the board said the incident had “led to changes across agencies”, including “better co-ordination between care providers” and with care co-ordinators.
“How patients are discharged and communication with private providers has also been reviewed, as has the way in which beds are allocated to people in the community who are experiencing a mental
health crisis and may pose a risk to themselves or others,” the board added.