PERFORMANCE: Sussex Partnership Foundation Trust missed three chances to identify the risk to the public posed by a patient who went on to stab a woman in a supermarket, according to an independent review

NHS South of England last week published the findings of an investigation carried out by the consultancy Verita into the care and treatment of a mental health patient known as Mr Z. 

In September 2008, the patient stabbed a 22-year-old woman more than 20 times in a supermarket. The woman survived. Mr Z was sentenced in 2009 for attempted murder and is currently detained indefinitely in Broadmoor Hospital.

At the time of the incident Mr Z was receiving mental health care from Sussex Partnership. The inquiry revealed three major “missed opportunities” for Mr Z’s clinical team to “thoroughly appraise or review his presentation, clinical and psychosocial needs and future risks”.

The first major opportunity was when Mr Z was admitted to psychiatric services in August 2007. The second chance was when he was transferred after five months on an acute admission ward, and the third was when he was later readmitted to hospital.

The report also noted the trust’s failure to work in partnership with Mr Z’s family, highlighting little evidence of staff attempting to establish a relationship with Mr Z’s mother who was a “very important part of his future care plan”.

Tim Ojo, executive medical director for Sussex Partnership, said the trust had “listened closely” to the report’s findings. “We have already taken all the necessary action to implement the lessons that we have learned, both from our own review in 2008 and this report which builds on our conclusions.”