An independent inquiry into the killing of a psychiatric patient has condemned the trust involved for its 'closed thinking' and 'failure to be open'with other agencies.
Wakefield and Pontefract Community Health trust comes in for damning criticism in a report into the death of Adrian Pawson in December 1998. Mr Pawson was stabbed 22 times by Daniel Williams while both were patients in the Priory unit. Mr Williams was found guilty of manslaughter on the grounds of diminished responsibility in February 1999 and transferred to Rampton Hospital.
An earlier internal investigation by the trust concluded that the attack could not have been predicted or prevented despite the fact that Mr Williams had managed to bring a set of knives onto the ward.
The latest independent report refutes this claim and says the report's conclusion hindered staff from learning from the incident.
'To categorise the killing as an entirely unpredictable event removes the need to invest energy in reducing the risk of similar incidents in the future, ' says the report, chaired by solicitor Jagta S Bhatoa.
'Minds are closed to the professional learning which should come out of the tragic events.'
Mr Williams was diagnosed with schizophrenia, used drugs and alcohol and had been assessed as potentially violent. He was admitted informally to hospital in December 1998 after being evicted from a hostel because other residents complained about his threatening behaviour. Mr Williams had bought a set of kitchen knives and was preoccupied with Nazi imagery.
After two days at Pontefract General Infirmary, which he was not allowed to leave unaccompanied, he was transferred to the Priory unit in Wakefield. He was allowed to go out alone and collected his knives from the hostel.
'At that time the clinicians were saying his mental illness was under control, ' said Ray Wilk, chief executive of the trust.
Mr Wilk countered criticisms of the trust's lack of openness. 'If people have picked that up as a perception, I have taken that on board. If there is something I need to change, clearly I will pick that up, ' he said He said there were four staff on duty that night and only nine patients. Asked why nobody heard any screams or cries, he said: 'There was the usual kind of noises that would have covered any kind of activity on a ward.
The television would be on. Staff were involved with other patients.
'This is not a time for blaming one person and seeking retribution, ' he added.
Complex Needs: report of an independent inquiry into the care and treatment of Daniel Williams.01924-814400.