• Two patients were attacked on a ward at St James’s University Hospital in Leeds
  • Attacker was a patient diagnosed with paranoid schizophrenia on their ward whose medication had been stopped
  • Independent report into the incident, leaked to HSJ, finds the attack was “probably preventable”
  • Inquest into the deaths of Ken Godward and Roger Lamb is ongoing

An independent investigation into the attack and killing of two people on a hospital ward by another patient has concluded the attack was “probably preventable”, a leak of its report reveals.

An independent investigation into the deaths of Ken Godward, 76, and Roger Lamb, 79, nearly four years ago also raises concerns about how the NHS handled families’ questions. It details how both Leeds Teaching Hospitals Trust and Leeds and York Partnership Foundation Trust resisted the independent investigation and sought changes to its terms of reference.

A final draft of the investigation report has been leaked to HSJ by an NHS source amid concerns among some of those involved that an inquest into the deaths, taking place this week, may not hear its findings.

NHS England, which commissioned the independent report in 2017, has not yet published the report, but said it had shared it with the coroner and planned to publish it.

Mr Godward and Mr Lamb were beaten with a walking stick by 70 year old Harry Bosomworth, who had been diagnosed with paranoid schizophrenia, at St James’s University Hospital in Leeds in February 2015. Mr Bosomworth had a history of violence, and his medication was wrongly stopped when he was admitted to the hospital despite repeated warnings by his stepdaughter.

Mr Godward’s family accused the hospitals of a “cover up” earlier this year when HSJ revealed the incident, but have declined to comment while the inquest is ongoing.

The leaked report of the investigation, carried out by the company Niche Health & Social Care Consulting, states: “We consider the tragic event of the 28 February 2015 was probably preventable.”

Its overall analysis says it “was, to an extent, preventable”. It identifies several reasons why this was the case, including that:

  • “There was opportunity to oversee and coordinate Harry’s physical and mental healthcare as his condition deteriorated.”
  • “There was an opportunity to assess Harry under the Mental Capacity Act which could have offered a helpful framework to deliver Harry’s care and treatment.”
  • “Harry could have been prescribed an immediately acting anti-seizure medication so that his olanzapine could have continued which would have prevented a relapse of his schizophrenia.”
  • “A decision could have been taken to nurse Harry in a side room [on the ward] rather than a four bedded bay, or to provide a Safety Guardian and the level of observation to keep Harry in eyesight at all times.”

The review also considered whether the incident was “predictable” and states: “We found that it was predictable that during a period of relapse, without medication, that Harry would develop persecutory thoughts about people…

“We found that the probability of violence, from 18 February 2015, was high enough to warrant action by professionals to try to avert it. However, we do not think that the extent of the violence and the tragic event of the 28 February 2015 could have been predicted.”

Examining the root cause of the attack, the investigation said a “major contributory factor” was the “lack of situational awareness between LTHT and LYPT about the impact of a relapse of Harry’s schizophrenia and the potential risk of harm to others”.

As a result of this, the report said Mr Bosomworth was not prescribed his anti-psychotic medication for 22 days despite his stepdaughter repeatedly warning of the risk he would become violent.

In the days leading up to the attack, Mr Bosomworth was recorded as hallucinating and hearing two male voices threatening him. He also threatened to kill staff.

Findings and recommendations in the report include:

  • An internal investigation commissioned by the trust, which said the incident was neither predictable nor preventable, did not have appropriate terms of reference. It “did not review the management actions following the incident or consider clinical audit data, patient safety data, complaints data, or the layout of the ward, location of patients, staff and equipment. It also inadequately covered issues raised by the families, the appropriateness of Harry’s care and treatment, compliance with local policies, national guidance and relevant statutory obligations, or the nursing management of the ward”. The terms of reference did not include an investigation of the incident and limited the review’s scope with only a single investigator appointed.
  • The report makes a series of recommendations for improving the trusts’ approach to internal investigations.
  • After the internal report, neither trust tried to address the families’ unanswered questions with the report saying the process of trying to seek answers was “unnecessarily distressing”. In one example, a relative was told by letter any further concerns would be addressed at the inquest which the report said was “inappropriate and inadequate”.
  • Both NHS trusts attempted to alter the scope of the investigation and change its terms of reference. Both trusts argued staff should not be re-interviewed to avoid causing them distress and that the internal investigation “had been of good quality and stakeholders felt that there was nothing to be gained by re-investigating the incident”. During the summer of 2017, Niche suspended its work at the request of NHS England which then issued revised terms of reference in September. It also had difficulty obtaining records and it was only after HSJ highlighted the delays that the coroner issued NHS England with a deadline for the final report.
  • The report highlighted staffing levels on the ward during the night of the attack, which were a ratio of one registered nurse to 15 patients and a ratio of one member of staff to seven patients. It said: “We believe that the care hours offered per patient was low and therefore are of the opinion that it was possible that there were not enough nursing staff on duty on the night shift.” It added: “There were 10 incident reports for the preceding 11 months where staff have felt that low staffing numbers had contributed significantly to insufficient care delivery.”
  • The report made a total of 21 recommendations to both trusts which included improving the way they work together, how they share information, training of staff and the need to meet with the families of Mr Godward and Mr Lamb to address their concerns.
  • The report identified some “good practice” including that it had commissioned an internal investigation from “an independent person” – notwithstanding its limitations – and that a nurse had discussed Mr Bosomworth’s medicines with his stepdaughter, “good practice that we do not always see elsewhere”.

An NHS England spokesman said: “The families affected by this incident have been closely involved in the investigation and both they and the coroner have had a copy of the final draft report, which will be published shortly, and which will set out the actions which need to be taken as a result of this inquest.”

Both NHS trusts expressed apologies for what had happened but declined to comment substantively while the inquest was ongoing.