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Healthcare Inspectorate Wales Publishes Reports of its Findings of a Homicide in Trecynon

• The killing of Father Paul could not have been predicted, however had Mr D received a full psychiatric assessment following a self harm incident in July 2006, a diagnosis of psychosis could have been made and appropriate treatment initiated. Had he received such treatment over a period of time and responded adequately, the risk of his committing an act of violence or homicide might have been reduced.
   
• Mr D’s mental state was never fully known to any medical services.

• A 40 minute delay in relation to the Psychiatric Liaison Team being able to see Mr D following an A&E attendance for self harm in July 2006 resulted in Mr D walking out of the department before a formal mental health assessment could be carried out.

• No follow up attempt was made by the Psychiatric Liaison Team in July 2006 to pursue assessment once Mr D was found to be back at his home in Trecynon and a lack of any attempt by the Psychiatric Liaison Team to alert community mental health teams or the GP of Mr D’s situation.

• Ambiguity regarding the level of concern communicated by the A&E department to the Psychiatric Liaison Team following the July 2006 attendance, due to the lack of a detailed record being available.

• The failure of services while Mr D was a child and adolescent to proactively engage Mr D and his family and provide long-term planning for the care and support of Mr D based on comprehensive assessment and analysis of risks, strengths and support needs. Little support was offered by local authorities to Mr D’s mother despite her requests.

• Mrs Bennett was asked by the 999 control centre handler to check on her husband despite the assailant still being present at the scene armed with a knife.

• There was an initial delay in identifying the correct address of the incident during the 999 call.

• CPR was not given to Father Paul prior to the arrival of the ambulance crew and a decision was taken by the ambulance staff not to resuscitate Father Paul as he appeared to satisfy the conditions as per the WAST Recognition of Life Extinct (ROLE) / Do Not Attempt Resuscitation (DNAR) policy.

• The WAST Recognition of Life Extinct / Do Not Attempt Resuscitation policy was unclear. The terminology ‘collapse’ was not clearly defined and it is specified that resuscitation attempts must be undertaken whenever there is a chance of survival, however remote.

• Mrs Bennett’s GP initially referred her to the CMHT specifically for bereavement counselling which they said it could not provide. This led to a delay of over two months between the incident occurring and Mrs Bennett being seen by the CMHT in relation to Post Traumatic Stress.

• There is a lack of formalised health or social care arrangements in place in relation to the wider community to respond to traumatic incidents of this kind which impact on a community other than through self referral of those affected to health and social care professionals.

"The death of Father Paul has had a significant impact on his family and on the local community. It is clear that Mr D’s mental health problems had gone undiagnosed and untreated for some time. While the homicide of Father Paul could not have been predicted, had Mr D received appropriate care and treatment the risk of him committing an act of violence or homicide might have been reduced.

 

For Father Paul’s widow the tragedy has been compounded by her experiences following his attack and we have made recommendations in our report that are aimed at ensuring the matters highlighted by her experiences are addressed".

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Source: Healthcare Inspectorate Wales (HIW)