Review finds man’s death preventable after psychiatric patient discharged with no care plan

The death of a pensioner who was murdered by a neighbour just days after he was discharged from a psychiatric unit was preventable, a review has concluded.

Daniel Atkins, who suffered significant mental health problems, was discharged on a Friday – when mental health support services are harder to access over the weekend – and he had no care plan in place, according to an independent review conducted on behalf of NHS England.

Atkins, referred to as Mr L in the report, was discharged on February 28 2014 and went on to murder his neighbour, Ronald Parsons, on March 2.

Mr Parsons (pictured), 71, was quiet and private and wanted to spend his retirement in peace in the flat he had worked all of his life to buy, the report states.

It was recommended that Atkins was discharged from the psychiatric intensive care unit (PICU) at Oxleas NHS Foundation Trust to a lower grade unit.

But he was discharged into the community where he went on to murder Mr Parsons a few days later.

After the murder, Atkins told police: “I’m sorry I did it when I punched my neighbour, I went wild and lost it”.

And later in court he said he had “done it for Her Majesty the Queen”.

Atkins, from Bromley, south-east London, was discharged “without putting in place proper plans to mitigate any risk he may pose”, the authors concluded.

The report highlights how before the incident, Atkins had been admitted to mental health services provided by Oxleas NHS Foundation Trust on 11 different occasions.

He had a history of violence and substance misuse.

The report concludes: “Mr L should not have been discharged from the PICU without an adequate and robust care plan. This care plan should have included plans to mitigate any risks Mr L posed to his neighbours or family.”

The authors added: “There is no evidence of victim safety planning.

“The decision to expedite the discharge interfered with the process of a considered and planned discharge.

“We heard at interview that not all professionals involved in Mr L’s care agreed with the discharge.

“Mr L should not have been discharged on a Friday, which was acknowledged by the professionals in his clinical team.

“We have concluded that the root cause for this incident lies within the decision to discharge Mr L directly into the community as opposed to admission to a low secure setting, or through a phased discharge process from an acute ward, without putting in place proper plans to mitigate any risk he may pose.”

They added: “Even if it was agreed by all to discharge Mr L, there should have been a robust and proper care plan in place to support him, as required by Trust policy and best practice guidance.

“This care plan should have involved the housing association and LBB Environmental Health, and fully considered and mitigated any risks to his neighbours arising from their complaints about his anti-social behaviour and noise. These concerns were known by the care team.

“Because this proper discharge care planning did not happen we believe that the death or Mr Parsons was preventable.”

In a statement, Oxleas NHS Foundation Trust said: “We would like to express our sincere condolences to the friends and family of Mr Parsons. We are very sorry that this tragic incident happened.

“We accept the findings in the report and are fully implementing the recommendations.

“We immediately undertook a board-level inquiry into this serious incident and actions from this inquiry have all been implemented.

“This will enable us to continue to minimise the possibility of such a tragic event occurring in the future.”

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