PERFORMANCE: An independent review has cleared Suffolk Mental Health Partnership Trust of responsibility for a murder by a service user, but has highlighted weaknesses at the trust.

NHS East of England asked Niche Health and Social Care Consulting to conduct an independent investigation into the care and treatment of John McFarlane, who was in contact with the trust before killing Mary Griffiths with a bolt gun in May 2009.

It concluded that while Mr McFarlane was referred to the trust in August 2008 and had a series of contacts with psychiatrists and a community mental health team, he had no “relevant history of violence”.

A decision not to admit Mr McFarlane was made for clinical reasons and the number of available beds at the trust was “acceptable”.

However, the report noted poor communication between health professionals and poor note taking. The investigators had “concerns about the way in which support was arranged” by health care professionals following a risk assessment.

Mr McFarlane had no care plan and there was no single professional responsible for his care, which meant “small changes” in his mental state went undetected.

The report also recommended the trust should “strengthen its leadership and co-ordination of the management of serious untoward incidents”.

Hadrian Ball, trust medical director, described Ms Griffiths’ death as “an absolute tragedy” but noted the investigation had “identified some weaknesses in our care”.

“Today’s report makes recommendations that are being acted on and closely monitored,” he added.