“Indefensible” release of mental patient who went on to kill

There were significant shortcomings in the care and treatment by the Welsh NHS and social care services to former mental patient Martin Davies, who killed Mrs Gwen Poole in Llanbradach, Caerphilly, on 24 March 2009.

That was the message today of NHS Wales Chief Executive David Sissling.

The Welsh Government commissioned Healthcare Inspectorate Wales (HIW) to look into the care and treatment provided to Davies, and whether his care was a factor in his killing of Mrs Poole.

The review by Health Inspectorate Wales found multi-agency failings in his care and said his release from hospital was indefensible.

It criticised Caeprhilly social services and Cygnet mental health hospital, in Weston super Mare, from which he was released.

Mrs Poole, 66, was stabbed in the street four times by Davies, who had a history of aggressive behaviour resulting from a range of mental problems including Aspergers Syndrome, schizophrenia and drug and alcohol abouse.
“This is a very serious and deeply distressing situation for all involved, and my thoughts are very much with the families of those affected,” said Mr Sissling.

“It is important that when such tragic events occur, we investigate thoroughly, identify any necessary changes and put in place measures to reduce the risk of such incidents happening again.

“We therefore commission an independent investigation following every homicide, if the perpetrator has been in contact with mental health services in Wales within the last 12 months.

“Such reviews may reveal failings in the level of service provided and it would appear that, in this case, there were significant shortcomings in the support, care and treatment afforded to Martin Davies.

“On behalf of the NHS and social care services in Wales, I would like to apologise to everyone affected by this tragedy.

“I will expect the local health and social care organisations to work together and with other partners to take the appropriate actions following this tragic case. We will also consider what actions might need to be addressed nationally.”

Dr Tony Jewell, Chief Medical Officer for Wales, said: “We issued guidance on care planning using the Care Programme Approach and Community Mental Health Team Working last year to ensure LHBs improve mental health services, speed up access to diagnosis and treatment and respond to people experiencing deterioration in their mental health so that they can be helped sooner.

“While risk can never be eliminated entirely, we must do our utmost to reduce it. Across Wales, we are making significant improvements in training clinical and other staff to ensure that they can assess effectively the risk that individuals pose to themselves and to others.

“By May of 2011, over 3,500 mental health professionals had received formal training in risk assessment, which is a significant number across Wales.

“I would like to assure people that these incidents are small in number and individuals with mental health problems are far more likely to harm themselves than others

.“Local organisations have action plans in place to address the recommendations made in the report, and this will be followed up with them by the Welsh Government.”