The frenzied attack carried out on Philip Ellison was said to have been “unforeseeable” by health experts, despite the lack of a full risk assessment on his paranoid killer.
An independent investigation, commissioned by Health and Social Care Advisory Service, cleared Lancashire Care NHS Foundation Trust of “a causal link” to the killing, but it was noted that some of the decisions made by the Trust had a detrimental effect on the maintenance of Robert Searle’s mental health.
The report, made public for the first time yesterday at a Primary Care Trust (PCT) Cluster meeting in Nelson, notes how Searle had become agitated at the Trust’s suggestion that he might have to move out of the supported tenancy home Glebe Close, Fulwood, Preston, he had been in since May 2006.
Other key concerns included:
l Five successive care coordinators failed to assess Mr Searle as a vulnerable adult and failed to use an inter-agency agreement to pool knowledge about the family.
l Detailed knowledge about Searle was not known to all those with responsibility for his care.
l The “poor” relationship between a care coordinator, staff at the supported tenancy and other mental health support staff contributed to an “ill-informed” plan for Searle’s future.
The report, which names Searle only as Mr X and Mr Ellison as Mr A, said Searle’s actions “had not been predicted by any staff who worked with him” and that “none saw him as a threat nor was there any indication of any assault or aggression to others. The attack on Mr A (Ellison) was not one that could be predicted at that time.”
Heather Tierney-Moore, chief executive of Lancashire Care NHS Foundation Trust, Richard Jones of Lancashire County Council and Dr Jim Gardner, medical director of The Lancashire PCT Cluster, apologised for the events leading up to the tragedy and said that “lessons had been learned”.
These lessons include Lancashire Care increasing risk assessments of individuals and the environment, carrying out multi-disciplinary reviews of service users, and using electronic records so that staff have full access to appropriate information.
A statement from the Ellison family was read at the PCT meeting by solicitor Philip Liptrot, which commended changes in policy.
It said: “Philip was a wonderful and loving husband and father.
“He was taken away from us nearly five years ago whilst doing a job that he loved.
“We are pleased that the Trust has since changed its policies and procedures and hope that the tragic lessons learned will prevent this from happening to other families in the future.”
When questioned after the meeting, Heather Tierney-Moore, chief executive of Lancashire Care NHS Foundation Trust, insisted that Mr Searle’s care had been “reasonable” and his accommodation in a supported living house had been “entirely suitable”.
But she also admitted that still only in specific cases do workers carry personal alarms, wear body armour, and work in pairs.
She said: “The level of risk posed by service users would not usually require staff to require such precautions.
“The purpose of Supported Living Accommodation is to encourage people to live independently in an environment that is like a private home.
“People are assessed on their suitability for such accommodation and are placed according to their clinical need.
“The trust has a lone worker policy which supports staff working in supported living accommodation and when undertaking visits, regular contact with team members is maintained at all times. If, when assessing a potential visit, risk factors are identified then two members of staff would work together with the service user and additional security devices including alarms would be utilised.”
Dr Gardner, whose organisation worked in collaboration with Lancashire Care and Lancashire County Council over Searle’s care, said: “The attack on Mr Ellison was not forseeable.
“The care received by Mr X (Searle) in the previous seven years was generally of a good standard, but some areas could have been improved. I hope that the resulting action plan will act as some form of comfort for those affected by this incident.”
He told the meeting of “three key lessons”, which were:
• Robust clinical governance
• Clear accountability and the need for organisations to work together
• A recognition of the impact that service changes can have on service users.
Richard Jones, director of adult and community services at Lancashire County Council, which employed Mr Ellison, said: “The attack could not have been predicted, but the report has identified improvements to be made.
“I apologise that Mr X’s (Searle’s) care could have been improved if these measures had been in place at the time.”
When questioned after the meeting, Mr Jones added: “Nothing could have been done to prevent what happened, but we can look at ways to improve care. The quality of the work we do is of upmost concern.”
Since the attack, Searle’s care coordinator has been dismissed, and Ms Tierney-Moore said that a “completely different chain of command” had been put in place at Lancashire Care NHS Foundation Trust.
The report states that the coordinator in question “performed poorly and did not fulfil his obligations under Trust policies.”
It also said: “He did not take an active role in care planning and his attitude to working with Mr Searle was an obstacle to progress.”
Ms Tierney-Moore declined to comment on whether any compensation payment had been made to the Ellison family.
• Read more on this story in tonight’s Lancashire Evening Post