A nine-year-old Lincoln boy’s drowning could have been avoided had his grandad, who was jailed for life over the death, had a less rushed discharge from a mental health ward.
Stewart Greene was angry because his daughter Joanne, 38, would not allow him to move into her home following his discharge from a psychiatric unit in Lincoln.
Joanne had urged staff not to release him due to her fears of what he might do.
Then, on December 23, 2014 whilst Joanne was out shopping, her father went on to drown her son Alex Robinson in the bath, just 12 days after his discharge. He was jailed for life.
A report by NHS England was published on Thursday, November 19 after an independent investigation into the care and treatment of Stewart Greene. He is referred to as “Mr T”.
The reports says his discharge from the mental health ward was “rushed” with “no clearly documented rationale or discussion leading to the sudden decision to discharge him”.
Mr Greene had been in and out of psychiatric units for nearly 20 years, including units provided by Lincolnshire Lincolnshire Partnership NHS Foundation Trust, and was diagnosed with a psychopathic personality disorder.
He had been threatening towards his family and trust staff in the past. He assaulted trust staff, but it would not have been possible for them to have predicted that his behaviour would escalate to the degree that it would, according to the report.
However, the investigating team did consider that there were actions that the trust staff could have taken that might have avoided him killing Alex.
The investigation team believes it would not have been possible to predict the incident, but it might have been possible to avoid it happening had he been discharged from in-patient care in a “planned and structured way with an enhanced package of care”.
The report details 13 recommendations for LPFT, as well as two for the local clinical commissioning groups, to further improve learning from this event, including in areas around discharge and transfer, and clinical response and engagement.
LPFT said it welcomed the publication of the report and all of the recommendations have been “acted upon and completed”.
After the publication of the NHS Independent Investigation, Alex’s mum Jo Greene described her son as a “vibrant, loving, and unique nine-year-old boy” and said she can “only hope lessons will truly be learnt from Alex’s death”.
She said: “We remain concerned and angry that Alex’s death was entirely preventable – had the numerous and repeated failings documented in this report not occurred.
“We know now (my dad) Stewart Greene was discharged without an adequate care plan, or even sufficient medication to keep him safe and well. That should not have happened.
“When we tried to raise serious concerns we were not listened to. That should not have happened. These failings placed our family at serious risk, and, we believe, ultimately cost Alex his life.”
Anita Lewin, Director of Nursing AHPs and Quality at LPFT, said: “On behalf of our trust, I would like to say how very sorry we are about Alex’s death.
“This was a terrible tragedy and our thoughts and sympathies continue to be with Jo, John and Alex’s family. No parent should ever have to experience the loss of a child and I cannot imagine the grief they continue to experience.
“We welcome the publication of today’s report, which makes a number of recommendations, all of which have been acted upon and completed.
“We note the finding in the report about the importance of listening to the views of the family and we now have a clear programme in place to support our staff to listen to family members and carers, involving them as partners in care.
“We continually seek feedback about all of our services and constantly strive to make improvements in the way we care for and treat our patients, working together with partner organisations in health and care to safely plan discharge from hospital and provide on-going support in the community.
“Whilst nothing will ever bring back Alex, we welcome the publication of today’s report and hope it goes some way towards bringing an element of closure and understanding about what happened and how we have acted to improve and learn from this terrible tragedy.”