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Better mental health treatment 'may have stopped murder'


The death of a man stabbed by a mental health patient could have been averted if the teams caring for him had been adequately supported to provide ‘assertive’ treatment.

Kevin Price was able to kill James Fortey, 44, because his care and treatment for psychosis linked to depression was not “assertive” enough and the staff who visited him were not adequately supported, the Healthcare Inspectorate of Wales said.

Price’s delusions and deteriorating mental state “was a significant warning of increased risk, either to himself or others”, but health workers caring for him did not identify the seriousness of these changes and take appropriate steps.

The report said, while the killing of Mr Fortey could not have been predicted, that if healthcare workers had identified the seriousness of the delusions and admitted Price to hospital the tragedy might have been averted.

The reported added that the leadership and management of the teams caring for Price was “ineffective” and their strategy of care “had not been properly implemented”, allowing inadequate attention to risk assessment.

According to the inspectorate, Price missed appointments with doctors which were not followed up, went through periods when he did not take his medication and the staff who treated him were not properly managed.

Healthcare workers from the Newport East Community Mental Health Teams, run by Gwent Healthcare NHS Trust and Newport City Council, were “for the most part unsupported by senior staff. Other than for one assessment conducted by a locum consultant psychiatrist, at no point was Price seen by a substantive consultant psychiatrist”, the report said.

Dr Andrew Goodall, chief executive of the Aneurin Bevan Health Board which replaced the Gwent Trust, and Stewart Greenwell, corporate director for care and customers for Newport City Council issued a joint statement which said: “This was a tragic case which has obviously had a profound effect on all those involved.

“We would like to reassure all those who require mental health services, and the wider public, that many changes have already been made to mental health provision in the Gwent area and we will continue to review our services, particularly in the light of the recommendations by Healthcare Inspectorate Wales (HIW). I would like to take this opportunity to apologise formally for shortfalls in service that have been highlighted by HIW.”


Readers' comments (5)

  • I suspect I won't be the only one who is sick of hearing chief executives, politicians, managers and all those who are complicit in cutting services and staff, apologise for deaths in the mental health system. The only changes that ever occur are 1. make those staff in post do even more with the same resources and 2. produce more paperwork to 'prove' it's being done.
    If things are improving why is it common practice to expect CPNs to now be jack of all trades - they now complete CHC assessments, deal with brokerage to buy services/care, complete continence assessments, run groups etc, etc all of which means that the available time to actually see patients is minimal.
    If you can get a psychotic patient admitted to a bed in their area (as rare as a hen's tooth) and if so much is being done why is it common practice to only have 2 staff on duty on an acute admissions ward with 19 patients?
    Dr Goodall these are not 'shortfalls' they are completely gaping chasms!

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  • case load management and cpa is the key surely. another observation is that often the least qualified member of a team is sometimes the person who can carry the the most serious client caseload. especially when the client has been in the system some time. risk can be under stated.

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  • These comments are very interesting. I have worked for the best part of 50 years and I am ashamed of the care now provided by the NHS. for people who are mentally ill.
    The emphasis seems to be, to be able to find a person to blame for events. The work that a CPN might have to do, can be something that he is not trained to do eg. to find a place for someone to live after leaving Hospita,l or to find the correct benifits for paients who are not coping with finances. I am ashamed that I have to visit people who live in hovels surrounded by drug dealers,or in crummy guest houses where they are abused by landlords.
    Is it right that a person who is deemed to be a danger to themselves or to others, are still living in the community simply because there id no bed to put them in? Is this alright? is it? NO IT IS NOT. But who cares?

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  • Mertha Nyamande RMN

    Mental health services have detereorated since the introduction of patient choice, which to my opinion works well in other health services save mental health and leaning disabilities. In such services, a high callibre of experienced and knowledgeable staff is required, where their knowledge and expertise is key to care provision, not patient choice or capacity options. What one needs when in distress or in crisis is someone to carry them through the crisis; a period of structured lifestyle that one can then continue after discharge.

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  • I am an ethical journalist looking at long-term problems in the mental health sector. I would be very grateful to hear from anyone with first-hand knowledge of the sector's problems, such as finding beds for those who need them, staffing numbers on acute wards, the amount of hours spent on paperwork, or any other issues affecting mental health provision. You can contact me on to discuss it anonymously.

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