A mental health trust has apologised following a review by the NHS into a series of homicides by patients, which criticised elements of care and risk assessment.

Sussex Partnership NHS Foundation Trust underestimated the risk posed by some of its patients, an NHS review of deaths linked to the Trust between 2007 and 2015 found. 

In that time, patients of the trust carried out 9 homicides, and another patient was killed while under the trust’s care.

Two of the 9 homicides were considered to be predictable or preventable, according to the independent investigation reports. The main common factor in these reports was improvements required in risk assessment and risk management.

The NHS review made a number of criticisms of the trust, including that there could be delays either between GP referral and initial assessment by the Trust; or between initial assessment by the Trust and access to more specialist assessment (for example, forensic services). 

However, the report noted that organisational changes have since led to shorter waiting times and access times to a number of specialist services have improved.

In 7 out of the 9 cases of homicide, there was criticism of the risk assessment process and/or the design of the risk management plan. In several cases, the process was seen as inadequate or the risk posed was not recognised or was seriously underestimated.

Systemic or professional problems were also identified. Several investigations reported that staff did not conform to local policies and/or national guidelines, such as NICE guidelines for treatment and care of people with psychosis not being followed and service users in long-term contact with the trust not being re-assessed for several years.

The review noted a tendency in mental health homicide investigation recommendations and Trust action plans to focus on processes and activities, such as re-writing policies or providing training. However, to improve the quality of care and treatment the trust provides, and reduce the likelihood of similar incidents recurring, the review suggested the focus move towards outcomes, changes in clinical practice – such as completing risk assessments across the Trust for all patients – and the impact of practice on stakeholders, including service users, carers, families, health care professionals and support staff, and the broader public.

In response, Sussex Partnership’s chief executive, Colm Donaghy, apologised to those affected by the incidents. “On behalf of the Trust, I want to offer my sincere apology and condolences,” he said.

“This review sends us a strong message about the need to identify and embed learning when things go wrong in a way that changes clinical practice and behaviour. This goes beyond action plans; it’s about organisational culture, values and leadership.

“Another key focus of the report is how we work with patients and families. This is something we don’t always get right. We’re doing a lot to improve this. But we need to keep at it and keep talking to patients and carers about what we can do better. That includes being prepared to listen to, reflect upon and respond to critical feedback in a positive way. We have appointed people with lived experience of using mental health services to our new, senior Patient and Carer leader roles to help us do this.

“We are also introducing Family Liaison Officer roles to provide a single point of contact and support for families affected by a homicide involving someone known to our services. This is something which was recommended to us by families who have been through this tragic experience themselves.”

Donaghy added that Trust staff work hard to provide the best possible care to patients, and that he wanted the organisation to be one that learns when things go wrong and does something about it, rather than one that blames people when they make a mistake. “This approach is in the best interests of patients because it will help us continue to improve. It is also why we commissioned this review with NHS England.”