Safeguarding adults reviews

Date of review

June 2024

Reviewer

Steve Chamberlain

Owner

Monuara Ullah, London Borough of Hounslow

Executive summary

This report has been anonymised to protect the confidentiality of the person who is the subject of the report and their family.

On 12 November 2021, Mr A attacked two members of the public with a knife in the street in Brentford. He did not know either victim. An 82-year-old woman was injured, requiring hospital treatment, and a 20-year-old man died as a result of the attack.

This review looks at the care and support provided to Mr A in the period from May 2020 to November 2021, when the incident which prompted this report occurred.

Mr A lived in a housing association rented property in Brentford since 2015. He had been the victim of a life-threatening assault in 2013 in which he received multiple stab wounds and needed major surgery. There was no evidence of mental ill health before this event, and Mr A was employed in a senior position at that time.

It is reported that Mr A was exhibiting anti-social behaviour, including harassment towards his elderly neighbour, intermittently from 2017. The concerns regarding Mr A’s behaviour escalated markedly in early 2020, coinciding with the first Covid-19 lockdown. During 2020, concerns focused on Mr A’s harassment of his neighbour and increasingly bizarre behaviour. This was initially addressed through the housing association, police and council Community Safety Team (CST).

As concerns increased regarding Mr A’s mental health, a referral was made to the NHS mental health service, resulting in a home visit by the crisis and home treatment team (HCATT) at the end of December. Notwithstanding significant evidence of mental disorder, including psychotic symptoms, the team discharged Mr A back to the care of his GP.

During the following five months, the situation continued to be managed through the Community Risk Panel, involving predominantly the CST, police and housing association. A Community Protection Warning was served which had some temporary impact. Mr A showed evidence of increasing environmental and self-neglect, alongside further evidence of mental ill health.

Further Merlin reports led to a further home visit by HCATT in May. The police had met with Mr A’s mother who was present at the time of one of their visits, and strongly advised that she be contacted to assist in engaging with Mr A. The team visited without speaking to Mr A’s mother, concluded Mr A had “full capacity” and again referred him back to his GP. Further responses from the trust identified Mr A’s problem as predominantly alcohol- and drug-related, and not primarily mental health.

In the context of ongoing concerns about Mr A’s mental health and the impact on his elderly neighbour, a letter was sent to the trust safeguarding lead from the CST. This was passed to the newly formed MINT (community mental health) team and Mr A’s case was allocated in mid-July.

Initial attempts to contact Mr A were unsuccessful, and there was no evidence of consideration to contact his mother, the housing association or police. No further action was taken until late September, following a further referral from the London Fire Brigade. A CPN from the MINT team visited in October and identified significant mental disorder. A decision was taken to discuss the case in the weekly clinical meeting, but this did not happen until two weeks later.

The police continued to have regular contact and on several occasions reported observing large knives in Mr A’s living room and on the arm of his chair. The police reported concerns about the increasing risk. An appointment was made for Mr A to attend an assessment appointment with a psychiatrist at the clinical base at the beginning of November, but he did not attend. A further appointment was made later in November at Mr A’s home address, but the incident occurred before this date.

Several themes emerge from the review, which while separate, are inevitably interlinked. It is notable that the HCATT team, which visited Mr A in December 2020 and May 2021 discharged him back to his GP on both occasions, despite significant evidence of mental disorder and psychotic symptoms. They determined he was not in mental health crisis at the time, and did not need immediate admission to hospital, but did not consider other forms of engagement. The team also identified Mr A’s primary problem as drug- and alcohol-related, rather than mental health and this information became the predominant narrative during the first half of 2021, in response to concerns from other agencies regarding Mr A’s presentation.

Once the case was allocated within the MINT team, the Care Programme Approach policy should have been followed, but no contact was made for almost three months. No communication was made with any of the other agencies involved, or with Mr A’s mother, and as a result there was no update regarding risks. The MINT team was newly established, and the NHS trust report notes the considerable organisational difficulties that this reorganisation caused at that time.

The lack of family involvement is linked to this theme. Mr A’s mother tried hard to obtain help for her son. She spoke to police at his property, attended the police station as appropriate adult, and also spoke to a mental health social worker on the telephone. She was not contacted by any other professionals, despite her own offers, and strong advice from the police that she would be helpful in enabling engagement with Mr A.

Mr A was assessed twice by HCATT as having “full capacity”, which had a significant impact on both decisions to discharge him back to the GP. While there is no evidence to refute either finding of capacity, it is vital that professionals are aware of the nuances of mental capacity, and a finding of capacity does not simply lead to the person being closed to the service. A person may still need significant support and further attempts at engagement. It is also vital to differentiate the Mental Capacity Act from the Mental Health Act (MHA). The two pieces of legislation have different purposes and different thresholds. There is a complex interrelationship between the two and professionals should be familiar with their respective roles.

Shortcomings in communication between agencies is closely linked to other themes. The police, housing association and CST had regular communication, but were unhappy with the response from the trust. Following allocation within the MINT team, there was no contact with police for a considerable period, or the housing association at all. Limited communication between the local authority and trust mental health teams in a disaggregated structure appears to have impaired the ability to consider Mr A’s situation in a holistic manner, taking his health and social circumstances into account, and thus creating a clearer identification of the risks.

As Mr A’s mental health deteriorated, at no time was the use of the MHA considered. The reviewer heard evidence that some professionals have found access to the local authority AMHP service problematic, with an expectation that all referrals must initially have been through the MINT or HCATT service. It is important that the AMHP service must be prepared to receive requests or referrals from a wide range of professionals, to reflect the duty set out in MHA section 13 for an AMHP to consider such cases. This will not necessarily always result in a full MHA assessment but will require the AMHP service to consider the case in some detail.

18 police Merlin reports regarding Mr A were submitted in the 16 months prior to the incident. These were shared with social care and the trust. It is reported that the final five reports were not received by the trust, but despite NHS Digital investigations, no reason has been given for this. These reports contain considerable evidence of Mr A’s mental ill health and the risks. There was no process in place to escalate the case to more senior staff, or a multi-agency meeting, due to the frequency and severity of these reports. Such a process would have enabled a more thorough investigation of Mr A’s circumstances, and the related risks.

The police were regularly involved in Mr A’s case, normally related to his anti-social behaviour and criminal actions. They responded through a community resolution process rather than pursuing criminal procedures. Given Mr A’s ethnic background and the local police officers’ firm view that his behaviour was caused by mental ill health, this could be seen as a less restrictive approach. On two occasions the police officers suggested using MHA section 135, but this is outside their powers and would require AMHP involvement. It has been suggested that creating crime reports for many of the reported incidents is likely to have led to a more senior oversight of the case, and possibly earlier escalation.

The reviewer considered the impact of the Covid-19 pandemic, and it appears that Mr A’s mental health deteriorated considerably during the first national lockdown. There is no evidence, however, that the restrictions caused by the pandemic and lockdowns impaired the ability of the professionals to respond to referrals.

Finally, the reviewer considered the impact of race and ethnicity in this case, as Mr A is a black British man of Caribbean heritage. The main concern regarding mental health and men of African and Caribbean backgrounds is of their over-representation at all levels of the compulsory and restrictive mental health service. The questions arising in this case are whether action should have been taken earlier, including maybe compulsion under the MHA, rather than over-use of compulsory powers. Mr A's mother repeatedly asked for help for her son, and his reluctance appears to be directly related to his psychotic symptoms. Mr A was identified as having a primary alcohol and drug problem, and while his alcohol consumption increased during 2021, there was no evidence at any point of use of illicit drugs. It is important that any conclusions are supported by clear evidence, to avoid creating a false narrative.

It is a tragedy that a life has been lost and another person was seriously injured. It is important also to be aware that Mr A is now confined at the most intense level of mental health restriction and is likely to remain there for a considerable period of time, and that he also is a victim of this chain of events.