A mental health trust has been told that if risks were better controlled, the likelihood of an attack in which a patient died would have been reduced.
However, NHS England’s independent inspection said the death of 60-year-old Robert McNeill, could not have been predicted or prevented.
Mr McNeill died after being attacked by fellow patient 26-year-old Jamie Reed in January 2017 at Great Oaks Hospital in Scunthorpe.
Reed was detained for 12 years in a secure unit after he was convicted of manslaughter by diminished responsibility following a trial at Hull Crown Court in July 2017.
In its report, NHS England said the “staffing levels and skill mix” on the ward had a “significant impact” on the conditions.
However, the most significant was the observation policy. If the observations had been carried out differently it would have reduced the likelihood that [Reed] would have been able to go into Mr [McNeill]’s room and be undisturbed for 15 minutes.
The report also said how staff had reported feeling unsafe on the ward, particularly on nights. It said they had raised concerns about staffing levels and had been “anxious about risk assessment and levels within the unit”.
“The tolerance of uncontrolled risk meant that staff did not have the resources or plans in place to manage risks effectively,” says the report.
“We cannot say that [Reed] would not have subsequently killed someone, but we can say that promoting a culture that is less tolerant of risk will reduce the likelihood of patient harm in the future”
Following the report, Dr Nav Ahluwalia, Executive Medical Director for Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) welcomed the investigation, and apologised to the families of both patients.
He said: “On behalf of the Trust I want to again offer our sympathies and thoughts to the families of both patients. We appreciate this is a very difficult time for them.
As the report states the Trust could not have predicted or prevented the events taking place. However, we know that we could have offered a better standard of care and treatment and we apologise for not doing so.
He said improvements made included an increased number of senior nurses working on the ward and the hospital’s psychology and occupational therapy input.
“Patient safety is paramount to us and I want to assure our current patients and their families that since this incident took place in January 2017 the staff and managers have worked incredibly hard to improve the ward environment, culture and the care we offer. We continue to work with our staff to ensure we strive to deliver the best care possible.
He said a “robust action plan” was in place to “drive through” NHS England’s recommendations.
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