William Myers · Prevention of Future Deaths report

On the 9th February 2016 an investigation was commenced into the death of William Myers, aged 79. The investigation concluded at the end of the inquest on the 19th January 2018. The conclusion of the inquest was that the deceased was unlawfully killed. The medical cause of death was:
1a) Multiple stab wounds

On the 7th February 2016 Mr Lound was killed by a man who had a long history of paranoid schizophrenia which had caused him to be compulsorily detained in high and medium secure psychiatric hospitals for many years before being released to supported accommodation in the community. This man pleaded guilty to the murder of Mr Lound and was subsequently sentenced to life imprisonment.

(1) The care and treatment provided to Mr Lound's attacker ('the attacker') in 2015/16 whilst in the community was inconsistent and/or inappropriate management strategy. Instead of being treated by the same team of psychiatric clinicians, he was admitted to four different psychiatric wards during 2015. The consultants involved in his treatment did not confer sufficiently to produce a clear management plan.

(2) A variety of incidents should have alerted the clinicians and others involved in his management to the need for a multi-disciplinary case conference reassessment by the Forensic Psychiatrist. Neither of these took place and in consequence warning signs of impending or actual violence were not recognised. Examples include being found by the Police in a public place in possession of a bladed article when under the influence of some illicit substance and admitting he was hearing voices commanding him to kill people.

(3) Valuable background information was not circulated to those involved in his treatment with the result that they were deprived of the crucially important medical history of the potential risks (particularly the attacker was no longer taking the medication which controlled his behaviour and was once again resorted to using illicit drugs). An example of this concerns a 20 page discharge report prepared by a Consultant Forensic Psychiatrist at the time the attacker was being prepared to leave Ashworth High Security Hospital. This report not seem to have been material to the Care Coordinator, the GP nor the Consultant Psychiatrist who undertook treatment on two different psychiatric wards and in the community.

(4) On three occasions during 2015 other clinicians who encountered the attacker recommended that a Mental Health Act assessment be considered with a view to him being detained. These recommendations were not acted upon. Judgements made by Consultant psychiatrists were not acted upon, preferably by a second opinion in the least, but preferably by a Forensic Psychiatrist, as this has been verified by the benefit of hindsight, the attacker's propensity to violent conduct may well have been triggers by a Mental Health Act assessment.

(5) Gaps in record keeping hindered the coordination of treatment. Examples included a void in the medical notes to explain why the number of letters had been transferred from one psychiatric ward to another (with a different consultant and clinical team), a discharge in his absence (taking place in October 2015) without any record of the assessment having been produced by the same team as to how the risk followed up and why he was to be benefited, nor an explanation as to who had authorised the discharge and the discharge was made.

Overall, the lingering concern is complex such as this are not identified early enough and managed by an identified and appropriately qualified psychiatrist. There should be a clear delineation of all the clinicians and agencies involved, by way of periodic case conferences with reasons and decisions made being recorded and circulated. The scarcity of inpatient psychiatric beds fuels the concern that complex individuals are being treated in the community rather than controlling the risks they present by having them remain in hospital until such crimes as their condition has been shown to have stabilised.