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NHS England commissioned Niche to conduct an independent investigation into the care and treatment of XX and to review the events that led up to an incident which led to the deaths of two elderly members of the public.
We were asked to determine on whether the events could have been predicted or prevented, to review the post internal investigation report and to monitor and evaluate the Trust’s progress in the implementation of the action plan that was based on the findings of the internal report.
XX was diagnosed with a panic disorder. In the months leading up to the incident XX had sporadic contact with community mental health services. XX also had a significant polysubstance misuse history. Since childhood XX had a chronic physical health disease which was progressively and significantly affecting both his mobility and ability to manage his own personal care.
This case met the criteria for the commissioning of an independent homicide investigation as set out in the NHS England’s Serious Incident Framework (2015). Our report was written with reference to the National Patient Safety Agency (NPSA) Root Cause Analysis Guidance.
As part of our investigation we undertook:
During the course of our investigation we identified the following significant issues that were either unknown to either primary and secondary mental health services or identified within the Trust’s internal report:
We concluded that even based on the partial and at times inaccurate information it was evident that XX had extremely high risk factors and few protective factors and that there was a significant probability that he would reoffend and that this was likely to have involved violence towards others. However even with improved interagency liaison and assessments given XX’s historical risks as well as his current chaotic lifestyle it was not evident to us if these changes would have prevented him from reoffending. Therefore, we concluded that the incident was probably not preventable.
Our report made a number of local and national recommendations. The Trust is currently implementing an action plan to address our recommendations identified. We are also currently providing on-going support to the Trust in order to improve the quality of their internal investigation processes.
NHS England presented our report at a press conference; following this launch our findings and recommendations received both local and national media attention