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.”