NHS England published an independent investigation into the circumstances surrounding the tragic death of S, in March 2013.
Q was receiving care from HPFT community services when he murdered S, who was the father of his ex-girlfriend. Q was sentenced to 27-years in custody for this murder. Following the incident, in 2013, the Trust undertook an internal panel review of this serious incident and an action plan was put in place to address the key areas of learning. Subsequently, NHS England commissioned an independent investigation under Department of Health guidelines, which apply when crimes of murder or manslaughter are committed by people who have been receiving a programme of care from mental health services.
The investigation team concluded that the incident was neither predictable nor preventable. It concluded that appropriate steps have been taken by Hertfordshire Partnership University NHS Foundation Trust to:
- Strengthen care planning and risk assessment
- Communicate effectively across inter-agency boundaries
- Provide an appropriate level of support and supervision to staff.
The team did not make any further recommendations. You can see the report here
Dr Jane Padmore, Executive Director, Quality & Safety commented: “We wish to express our heartfelt condolences to Mr S’s family. We always seek to learn from such tragic events by undertaking an internal review. I am reassured that the independent investigation has verified the recommendations of this review.”