A mental health trust underestimated the risk posed by its patients and sometimes did not act on threats to kill, a review of 10 killings over eight years has found.
The review examined deaths linked to Sussex NHS Partnership Foundation Trust patients between 2007 and 2015. The review of what is one of England’s largest mental health trusts was launched following the stabbing to death of Donald Lock, 79, by Matthew Daley in 2015.
Daley, who had been under the care of the trust at the time, was convicted of manslaughter on the grounds of diminished responsibility after stabbing Mr Lock 39 times following a collision between two cars on the A24 in Findon, West Sussex.
During the trial, jurors were told Daley’s mother had pleaded with mental health experts to have her son sectioned.
The review looked at nine killings committed by patients of the trust and the case of one patient who was killed while under the care of the trust. It found killings by Kayden Smith in 2012 and Roger Goswell in 2007 had been “preventable” and “predictable”.
Smith killed Danish tourist Jan Jansen at his flat in Hassocks, while Goswell, who was also a patient, killed his wife Susan in West Chiltington before taking his own life.
The independent review commissioned by the trust and NHS England found that, in several cases, the process to assess patients was “inadequate” and “the risk posed by the service user went unrecognised or was severely underestimated”.
In some cases, “risk assessments were not completed or were completed incorrectly”.
The report said: “Some diagnoses are incorrect and remained unchanged in the face of the service user’s behaviour.
“Sometimes service users made threats to kill others but no further action, for example informing the police or warning the person threatened, was taken.”
It added: “If the service user had been assessed as high risk, then a management plan would have been triggered.”
The report said learning after each killing had not always been taken up across the trust and there was some “repetition” in the recommendations made after each one.
The trust has apologised and offered its condolences to families.
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