Discharge rules from medium secure units in Wales to be reviewed after stabbing
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《英国医生杂志》
Arrangements for planning discharges at medium secure units in Wales are to be reviewed after an investigation into the case of psychiatric patient, Paul Khan, who fatally stabbed a stranger. The investigation identified a series of system failures—including a failure to apply a "12 hour missing" rule, which would have alerted the Home Office to the disappearance of 35 year old Mr Khan.
The inquiry team also said that they had difficulty understanding how Mr Khan, who had been admitted to Ashworth Maximum Security Hospital, Merseyside, seven years previously for an unprovoked knife attack, could have been transferred from medium secure accommodation to independent living within a few months.
Eighteen months ago Khan killed 72 year old Brian Dodd in Prestatyn, north Wales, by stabbing him at least 28 times. At the time, Mr Khan, who had been diagnosed with paranoid schizophrenia at 26, was under the care of the community forensic psychiatric team at Whitchurch Hospital, Cardiff, and was living in independent accommodation.
After the fatal stabbing in north Wales Cardiff Local Health Board was asked to commission an independent external review of the care management arrangements and the events leading up to the killing. The report identifies a number of areas of concern and makes a series of recommendations.
About accommodation it says, "The team found it difficult to understand how could essentially transfer from conditions of medium security to independent living within a total period of only nine months. Given offending history, the seriousness of the offence leading to him being detained in Ashworth Hospital, the inadequate hostel supervision and the relatively short period of time spent in the community, it felt his transition to independent living was not only completed too quickly but also without sufficient time based evidence of successful rehabilitation, in particular when considering the seriousness of the previous offence committed."
The team also highlights the failure to implement an arrangement which would have raised the alarm after Mr Khan was missing for 12 hours. "Notwithstanding the offence had already been committed, the failure to notify the police or the Home Office until three days later was a significant failing resulting in a situation where was effectively out of the area whilst presenting a serious risk to public safety and without instructions to recall him being considered or put in place," it says.
Ann Lloyd, Head of the Welsh Assembly Government抯 health and social care department, said, "Health Commission Wales has been asked to undertake an audit of discharge planning arrangements from medium secure units across Wales. They will be supported by Healthcare Inspectorate Wales who will simultaneously undertake a clinical governance inspection. This will get underway before Christmas."(Abergavenny Roger Dobson)
The inquiry team also said that they had difficulty understanding how Mr Khan, who had been admitted to Ashworth Maximum Security Hospital, Merseyside, seven years previously for an unprovoked knife attack, could have been transferred from medium secure accommodation to independent living within a few months.
Eighteen months ago Khan killed 72 year old Brian Dodd in Prestatyn, north Wales, by stabbing him at least 28 times. At the time, Mr Khan, who had been diagnosed with paranoid schizophrenia at 26, was under the care of the community forensic psychiatric team at Whitchurch Hospital, Cardiff, and was living in independent accommodation.
After the fatal stabbing in north Wales Cardiff Local Health Board was asked to commission an independent external review of the care management arrangements and the events leading up to the killing. The report identifies a number of areas of concern and makes a series of recommendations.
About accommodation it says, "The team found it difficult to understand how could essentially transfer from conditions of medium security to independent living within a total period of only nine months. Given offending history, the seriousness of the offence leading to him being detained in Ashworth Hospital, the inadequate hostel supervision and the relatively short period of time spent in the community, it felt his transition to independent living was not only completed too quickly but also without sufficient time based evidence of successful rehabilitation, in particular when considering the seriousness of the previous offence committed."
The team also highlights the failure to implement an arrangement which would have raised the alarm after Mr Khan was missing for 12 hours. "Notwithstanding the offence had already been committed, the failure to notify the police or the Home Office until three days later was a significant failing resulting in a situation where was effectively out of the area whilst presenting a serious risk to public safety and without instructions to recall him being considered or put in place," it says.
Ann Lloyd, Head of the Welsh Assembly Government抯 health and social care department, said, "Health Commission Wales has been asked to undertake an audit of discharge planning arrangements from medium secure units across Wales. They will be supported by Healthcare Inspectorate Wales who will simultaneously undertake a clinical governance inspection. This will get underway before Christmas."(Abergavenny Roger Dobson)