An independent investigation into the care and treatment of Mr G Jointly commissioned by: South West Strategic Health Authority and East Midlands Strategic Health Authority January 2012 Authors: Brendan Ward Chris Brougham © Verita 2012 Verita is an independent consultancy that specialises in conducting and managing investigations, reviews and inquiries for public sector and statutory organisations. Verita 53 Frith St London W1D 4SN Telephone 020 7494 5670 Fax 020 7734 9325 Email: [email protected] Website: www.verita.net 2 Contents 1. Introduction 4 2. Terms of reference 6 3. Executive summary and recommendations 11 4. Mr G: The early years (1977–1995) 24 5. Adult years in Kettering (1995–1996) 32 6. Initial years in Devon and Cornwall (1996–1997) 35 7. Camborne, Cornwall 1997–1999 41 8. Prison and the return to Camborne: April 1999–July 2001 47 9. Camborne: 2001–May 2003 58 10. Return to Northamptonshire in 2003 69 11. Late 2004 until early January 2005 84 12. Arrival in St Austell 88 13. Partner B and Child 4: St Austell, 2005 104 14. Period spent at Mr V‘s flat 107 15. Identifying gaps or omissions in previous reviews 121 16. Recommendations 139 Appendices Appendix A List of interviewees 143 Appendix B Mr G contacts with statutory services August 2005 to July 2006 145 Appendix C Children (Leaving Care) Act 2000 149 Appendix D Responding to a diagnosis of personality disorder 152 Appendix E Care Programme Approach 153 Appendix F Multi Agency Public Protection Arrangements (MAPPA) 157 Appendix G Domestic abuse 159 Appendix H Safeguarding adults 162 Appendix I Description of services 164 3 1. Introduction 1.1 This report provides an independent account of the care and treatment of Mr G who killed Mr V on 6 July 2006. 1.2 Mr V was a 43 year old man with a learning disability who was identified as vulnerable. The year before he died he moved into a one-bed flat in St Austell. After his death, Cornwall adult protection committee commissioned a serious case review to see if there were any lessons about how local professionals and agencies worked together to safeguard vulnerable adults. 1.3 NHS South West (the strategic health authority) commissioned this independent investigation into the care and treatment of Mr G with the full cooperation of Cornwall Partnership NHS Trust1, Cornwall and Isles of Scilly Primary Care Trust, Cornwall County Council, Northamptonshire Healthcare NHS Trust2, and South Western Ambulance Services NHS Trust. The investigation was commissioned in accordance with guidance published by the Department of Health in HSG 94(27), Guidance on the discharge of mentally disordered people and their continuing care in the community, and the updated paragraphs 33-6 issued in June 2005. It also takes into account the Good practice guidance issued by the National Patient Safety Agency in February 2008. 1.4 The amendment to the health service guidelines (HSG 94(27)) published in June 2005 proposed three purposes for an independent investigation: openness — the investigation should provide an open, transparent, factual and independent account of the incident and all associated matters learning lessons — finding out what has gone wrong and proposing how performance can be improved while balancing individual accountability with criticism of organisational systems and processes creating the circumstances for change and service improvement — making recommendations that help NHS organisations improve and develop and creating a climate in which organisations and individuals accept and act on what the report says. 1 Cornwall Partnership NHS Trust became a foundation trust in March 2010 and is now known as Cornwall Partnership NHS Foundation Trust. 2 Northamptonshire Partnership NHS Trust became a foundation trust in May 2009 and is now known as Northamptonshire Healthcare NHS Foundation Trust. 4 1.5 Verita, a consultancy specialising in the management and conduct of investigations, reviews and inquiries in public sector organisations, was commissioned to carry out this investigation. The investigators were Brendan Ward, a Verita associate, and Chris Brougham, one of Verita‘s senior investigators. Both have wide experience of managing health services and conducting reviews and investigations. The investigation team was supported by Dr Jayanth Srinivas, a consultant forensic psychiatrist from the Hatherton Centre in Stafford, who provided professional advice. Acknowledgements 1.6 We would like to thank everyone who gave up time to give evidence to the investigation and who spoke so freely to us. Their contributions and reflections form the basis of any learning that can be usefully applied in the future provision of services. 5 2. Terms of reference 2.1 The terms of reference for this investigation were to: investigate the care and treatment of Mr G, including risk assessment and management produce a comprehensive chronology of the contacts between Mr G and the health and social care agencies and other appropriate agencies from the date of his first contact with the NHS in 1991 identify gaps and omissions in the reviews carried out so far evaluate these gaps and omissions in order to make recommendations for the local health community. This investigation was not a disciplinary process. The investigation methodology 2.2 The investigation comprised three phases. The first phase resulted in the presentation of a tabular comprehensive chronology (with commentary) of the care and treatment of Mr G by health and social care services and his contact with other relevant agencies. The chronology starts in 1991 and includes his contacts with relevant agencies in Cornwall, Northamptonshire and London. The tabular chronology was discussed at a meeting with NHS South West in June 2009. 2.3 As a result of the complexity of involvement with various agencies, an additional narrative chronology of more than 100 pages was developed by us from the case notes. This afforded a valuable method of cross-checking information through the individual interviews. 2.4 The development of both chronologies formed the basis of the second phase of the investigation. 2.5 The second phase consisted of an evaluation of the various NHS and other investigations and reviews carried out to date with the purpose of identifying gaps and omissions. We reviewed the internal investigation by Cornwall Partnership NHS Trust, the independent quality assurance review commissioned by the trust and the serious case 6 review commissioned by Cornwall adult protection committee. We took into account the issues and recommendations identified by the chair of the Mr V serious case review dated December 2007. This was commissioned by the adult protection committee for Cornwall. We also took into account the chairs subsequent review and correspondence. 2.6 The third phase consisted of an evaluation of any relevant gaps and omissions, and included interviews with key NHS staff and those from relevant other agencies such as social services and the police. We looked primarily at organisational systems and processes, and in particular how different agencies worked together and at the governance arrangements supporting inter-agency working. 2.7 We conducted our work in private. 2.8 NHS South West obtained written consent from Mr G for access to any of his health or other records relevant to this investigation and to make the report public knowledge through publication of this report. 2.9 We met with Mr G to explain the terms of reference, to explain and discuss the process of the investigation and to hear his comments. 2.10 We wrote to the relatives of Mr V through a manager from the learning disability directorate of adult care and support at Cornwall County Council explaining the process of the independent investigation and enclosing a copy of the terms of reference. The manager told us that Mr V‘s nearest relative did not want to be involved in or contribute to this investigation. We wrote to the relatives again with an open invitation to see us at any point during the investigation but they did not take up this offer. We understand and respect their decision not to be involved. 2.11 The documentation we reviewed included Mr G‘s clinical notes from Cornwall Partnership NHS Trust, Cornwall children‘s and adult social services, South Western Ambulance Service NHS Trust, Northamptonshire mental health services, probation services and GP records. We gathered chronologies of events leading up to the murder which had previously been developed by the police and Cornwall social services. We also looked at incident reports, trust policies and procedures, board minutes and other relevant committee papers. In total we considered more than 6,000 pages of case files and operational policies. Some agencies submitted summaries of their involvement with Mr G 7 either because there was so much source material or references to Mr G were contained in case files for other clients. It was not possible to access historical case records from the specialist children‘s centre in Newton Aycliffe or the earlier notes from the probation service because services were unable to locate them. 2.12 We interviewed 44 people — see Appendix A for a list of interviewees. 2.13 We followed established good practice in the conduct of interviews. Interviewees were given the opportunity to be accompanied by an advocate or friend and to comment on the factual accuracy of the transcript of their evidence. Those criticised were shown extracts of the draft report so that they had the opportunity to comment before the report was finalised. 2.14 Part of the complexity of this case related to the number of agencies that had contact with Mr G at any one time, not always with the knowledge of others. 2.15 We set out a narrative of the main chronological events in the main body of the report so as to help the reader understand the key events and to provide an analysis of them.