Care failures criticised for mentally-ill killer
HEALTH services in West Wales have been criticised following a review into the killing of an 84-year-old woman by her mentally-ill son.
Inspectors found that there were staff shortages in the Pembrokeshire area that led to staff having to cover too wide an area, leading to shortcomings in the care of paranoid schizophrenic Jarvis Ford, aged 48.
Ford, who has been detained indefinitely under the Mental Health Act, killed his mother Margaret with a knife, stabbing her nine times after a row about smoking in the house on May 16, 2009.
He pleaded guilty to manslaughter on the grounds of diminished responsibility at Swansea Crown Court later that year.
The Healthcare Inspectorate Wales said nobody could have predicted the violent outburst that led to Jarvis Ford killing his mother.
A spokesman said: “While the homicide committed by Mr Ford was not predictable, there were shortcomings in the care and treatment he received during his engagement with mental health services in Pembrokeshire.”
Ford and his mother moved to Pembrokeshire from Solihull in 2007 to be nearer to other family members.
The review also criticised the way care arrangements for Ford, who had been diagnosed with schizophrenia in 1985, were transferred from the West Midlands to West Wales.
It said: “The arrangements for the transfer of Mr Ford’s care from Birmingham and Solihull Mental Health NHS Trust to South Pembrokeshire Community Mental Health Team were less than optimal, and that a direct referral would have enhanced communication on risk and relapse factors.”
The summary continues: “Insufficient regard was given to Mrs Ford’s role as a carer for her son, and the potential for her to require care as an elderly and vulnerable adult.”
And it warned that the care Ford received was “not sufficiently robust, which meant that opportunities to develop appropriate contingency and crisis plans to manage the risks posed by relapses were missed”.
It added that the family had difficulty contacting mental health workers when his condition worsened because “carers and family members had to engage in a frustrating and cumbersome process to contact various practitioners… and communication between these teams was also inefficient”.
In a joint statement, the Hywel Dda Health Board and Pembrokeshire council accepted the findings.
The Health Board said: “We can confirm that in conjunction with Pembrokeshire council and other agencies, we have implemented a range of changes and improvements to local mental health services, which not only respond to the key recommendations from HIW, but also aim to improve the delivery of local mental health services.
“A robust, detailed action plan has been produced. This clearly demonstrates that significant progress has already been made to address HIW’s recommendations.
“Whilst this tragic incident happened before the formation of the Hywel Dda Health Board, we now have an opportunity, under new leadership and within the new integrated organisational structure to learn lessons from this incident and to integrate health and social care services to provide a more seamless delivery of care for all our clients.”
Chief executive of HIW, Dr Peter Higson said: “This is a tragic case but it is important to stress that incidents like this are extremely rare.
“While our review concluded that this homicide could not have been predicted, it has highlighted a number of shortcomings.”
Angela Watwood, of Pembrokeshire council said: “We would wish to offer reassurance that the new Health Board and the County Council are committed to making mental health a key priority for the local population and the Health Board will continue, with our partners, to review and ensure that improvements to services are maintained and developed further.”