Dr Geraint Brierley Hughes · Prevention of Future Deaths report

On 3/12/13, an inquest was opened into the death of Dr Geraint Hughes who died on 15/11/13. The inquest culminated in a final hearing on 14th & 15th August 2019 with a Conclusion recorded that Dr Hughes was Unlawfully Killed.
The cause of death identified at post-mortem was:
1A) Stab wound to chest.

The deceased’s wife had been allowed home leave from a hospital ward. She had been diagnosed with severe depression and anxiety with fluctuating psychotic symptoms. While the risk she posed to herself had been assessed, there had been no assessment of the risk she posed to others. There was no history of violence and no other warning markers.
On 15/11/13, Doctor Hughes was stabbed once in the chest by his wife. He died at his home address.
████████ subsequently pleaded guilty to a charge of manslaughter on the grounds of diminished responsibility.

1) In the Trust’s own Serious Incident Report and the separately conducted Domestic Homicide Review, it was noted that a formal carer’s assessment had not been completed with Doctor Hughes. It was noted that while this could not be said to have been causative of the outcome, nevertheless, it represented a departure from best practice.
I was advised that the Trust’s electronic case management system (Rio) was now capable of customisation and had been adapted to ensure that a carer’s assessment was mandatory in cases where domestic abuse was present.
It may be that you will feel, on reflection, an audit of compliance with this requirement may be useful in assessing how robustly the Trust is performing in this regard. You may also feel it noteworthy to reflect that, in the instant case, there had been no record of domestic abuse. You may wish to consider whether it is appropriate to mandate a carer’s assessment in slightly wider, clearly prescribed circumstances.
2) The reviews into the circumstances of this death had also identified a lack of regular contact by the case coordinator. In turn, this meant that care plans and risk assessments were not regularly updated. Of note, this has not been identified in the usual supervisory reviews.
You may wish to reflect how the supervisory arrangements can be made more robust to prevent repetitions of this occurring in the future and, accordingly, reduce the risk of similar fatalities from happening again.