A knife attack on an innocent member of the public could have been prevented had the individual responsible received appropriate mental health care, an Ombudsman has said.
Failings in care
The Parliamentary and Health Service Ombudsman (PHSO) concluded that the 31-year-old man, who has since been diagnosed with schizophrenia, was provided with 'poor mental health care' by the Kent and Medway NHS and Social Care Partnership Trust, now known as Kent and Medway Mental Health NHS Trust. According to the PHSO, the trust was responsible for a 'series' of failings in the 12 months leading up to the stabbing incident in November 2020.
'This is a sad case involving a vulnerable man who posed a risk not only to himself but to others,' said Rebecca Hilsenrath, chief executive officer of PHSO. 'A risk that tragically became reality when he attacked an innocent member of the public. It highlights the stark consequences of poor mental health care, not just for patients, but also for their families, carers and even strangers.'
The PHSO said the failings included poor care planning and discharging the patient without reviewing his risk level. They said this might have contributed to the man's mental health decline. And had the man received safe and appropriate care, the stabbing might not have occurred, the PHSO said.
Mother's pleas for help
The Ombudsman launched an investigation after the patient's mother, a 57-year-old, complained about the care her son received. The woman, who chose to remain anonymous, said her son began struggling with symptoms of paranoia and anxiety in early 2019, and he was detained by police and admitted to hospital in October. In April and May 2020 the woman repeatedly contacted the mental health team, reporting behaviour including her son ripping up blinds and carpets, placing furniture in the garden and blocking her from leaving the house. She told staff she was 'frightened' and had hidden in the car for hours, and she tried to get help.
The PHSO said the trust knew the man was in crisis but failed to develop a care plan, and instead told her to contact police – falling short of national guidelines. He was later arrested on suspicion of criminal damage and detained in hospital, but in June 2020 he was released to the community. In the three months that followed – during the Covid-19 pandemic – the man received three phone calls but was not seen by the care team in person. He was discharged from the trust's care in October. One month later he stabbed a member of the public – a man in his 30s.
Distress and fear
The Ombudsman found the failings left the man's mother in distress for over a year and caused her to fear for her safety. The mother said: 'I was too scared to be in my home, so I sat in my car for hours calling staff begging them to help. For months I was telling them he was in psychosis. I was terrified. They offered no real help. They failed my son, they failed me, and they failed the person he hurt. Before he committed this crime, he had never been violent. I have no doubt that he hurt someone because of the failings of the community mental health team.'
Ms Hilsenrath added: 'The patient's mother repeatedly raised concerns about her son's deteriorating condition and the risks he posed. She was so fearful that she felt forced to hide in her car rather than remain in the home they shared. Despite her repeated pleas for help, she was badly let down by the trust and left to cope alone without the support she urgently needed. For over a year, she endured a frightening and distressing situation. During periods when her son was in crisis, her requests for help went largely unanswered, leaving her in fear for her safety. There is still significant work to be done to embed a culture within mental health services that learns from past mistakes. While there have been some improvements, including steps towards reform of the Mental Health Act and ongoing Government inquiries, these must lead to real change on the ground – change that improves services and keeps people safe.'
Trust response
A Kent and Medway Mental Health NHS Trust spokesperson said: 'This was a deeply serious and complex case, and we recognise the distress experienced by the family. Concerns raised in 2021 were fully investigated, including through close engagement with the Parliamentary and Health Service Ombudsman, and we have been open and transparent throughout that process. We apologise for where care and support did not meet expected standards and have taken action to strengthen community mental health services in line with the National Community Mental Health Framework.'
