A report by Healthcare Inspectorate Wales (HIW) into a homicide committed by a man with paranoid schizophrenia has concluded that the incident “could not have been predicted”.
The report, which was published today, was ordered by the Welsh Assembly Government following an attack on Father Paul Bennett by Geraint Evans outside the vicarage at St Fagan’s Church, Trecynon, Aberdare in March 2007. Until his arrest Mr Evans – who following a Crown Court hearing in October 2007 is being detained indefinitely at a high security psychiatric unit – had never been under the care of psychiatric services.
The main findings of the reports are as follows:
• The death of Father Paul could not have been predicted. However, had Mr Evans received a full psychiatric assessment following a self-harm incident in July 2006, a diagnosis of psychosis could have been made and appropriate treatment initiated. Had he received such treatment over a period of time and responded adequately, the risk of his committing an act of violence or homicide might have been reduced.
• Mr Evans’ mental state was never fully known to any medical services.
• A 40 minute delay in relation to the Psychiatric Liaison Team being able to see Mr Evans following an A&E attendance for self-harm in July 2006 resulted in Mr Evans walking out of the department before a formal mental health assessment could be carried out.
• No follow up attempt was made by the Psychiatric Liaison Team in July 2006 to pursue assessment once Mr Evans was found to be back at his home in Trecynon and there was a lack of any attempt by the Psychiatric Liaison Team to alert community mental health teams or the GP of Mr Evans’ situation.
• There was ambiguity regarding the level of concern communicated by the A&E department to the Psychiatric Liaison Team following the July 2006 attendance due to the lack of a detailed record being available.
• There was a failure of services, while Mr Evans was a child and adolescent, to proactively engage Mr Evans and his family and provide long-term planning for the care and support of Mr Evans based on comprehensive assessment and analysis of risks and support needs. Little support was offered by local authorities to Mr Evans’ mother despite her requests.
Four recommendations were set out in the report including, in relation to attendances at A&E, that “Health Boards should ensure patient records are reviewed thoroughly at every attendance so as to highlight any developing concerns that may emerge in light of past attendances.”
Commenting on the report’s findings Hafal Chief Executive Bill Walden-Jones said: “With hindsight there are a number of lessons to be learned which could reduce the risk of such a tragedy happening in future. The key problem in our view was the failure to follow up on Mr Evans after he attended A&E having cut himself very severely. Even though he did not necessarily display a risk of harm to others at this point, the public would nevertheless expect this incident to have been followed up because of fears for the safety of Mr Evans.”
Chief Executive of Health Inspectorate Wales, Dr Peter Higson, said: “The death of Father Paul has had a significant impact on his family and on the local community. It is clear that Mr Evans’ mental health problems had gone undiagnosed and untreated for some time. While the homicide of Father Paul could not have been predicted, had Mr Evans received appropriate care and treatment the risk of him committing an act of violence or homicide might have been reduced.”
To read a summary and access a PDF of the report please visit: http://www.hiw.org.uk/news.cfm?orgid=477&contentid=13771