PERFORMANCE: Failure to appreciate the complexity of patients’ conditions, low staffing levels and inadequate supervision contributed to two patients being treated by a South West mental health trust going on to kill.

Mr B, who suffered from obsessive compulsive disorder, killed his stepfather in a violent attack in Swindon in 2007.

An independent report, published by NHS South West last week, found the Avon and Wiltshire Partnership Trust community mental health service team responsible for Mr B had lacked capacity and knowledge.

It said the team showed an “overriding inadequacy” in its failure to appreciate the “complexity” of Mr B’s needs. This was compounded by the fact staff had not followed NICE guidelines on managing patients with OCD, the report said.

Mr B, who was 48 at the time of the attack, was the third AWP patient to kill a friend or relative within a five month period in 2007. The trust’s foundation trust application was put on hold in 2010 pending the outcome of investigations into the deaths. Two previously published reports (news, page 14, 1 December 2011) also critcised staffing levels.

In a statement chief executive Laura McMurtrie said changes had been made since 2007.

The trust also faced criticism, along with Cornwall Partnership Foundation Trust, in an independent report into another homicide published last week.

Mr Y, a heavy drug user who had been diagnosed with a conduct disorder and paranoid schizophrenia, stabbed a friend 13 times following a row in a house in Cornwall. He had moved between Bristol and Cornwall frequently throughout his life and had been treated by both mental health services.

An independent report into the case of Mr Y said the fact Mr Y had not been seen by anyone from the mental health team in Bristol for six weeks following discharge from a secure unit in 2004 was “not acceptable” and allowed him to become “lost” to services. It concluded opportunities were missed to address Mr Y’s needs, as staff focused on his conduct disorder and failed to give “necessary and appropriate consideration” to his schizophrenia.

The report found Cornwall Partnership Foundation Trust, whose care Mr Y was under when the incident happened in 2006, also missed opportunities to provide support for the “highly disturbed and challenging young man”.

Cornwall medical director Ellen Wilkinson said the trust accepted the findings of the report and had made improvements since 2007.