MENTAL health bosses have apologised for failings in the care of a patient who brutally killed two people in their own homes.

As a result of deficiencies in the care of James Allen, independent investigators recommended a 10-point action plan for primary and secondary care services - including domestic violence training for medical staff.

The NHS ordered an investigation into the treatment of James Allen after he murdered Colin Dunford, 81, from Middlesbrough and Julie Davison, 50, from Whitby during a three day period in April 2012.

Darlington and Stockton Times:
VICTIMS:  Julie Davison, 50, from Whitby and Colin Dunford, 81, from Middlesbrough

After his conviction at Newcastle Crown Court, Allen was jailed for 37 years.

Karen Conway, head of investigations for NHS England North, said it was clear that the care provided “could and should have been better and fell well below expected standards.”

The investigation concluded that while services should have identified that there was a “significant” probability” that he would re-offend his choice of victims could not be predicted.

Despite Mr Allen repeatedly reporting his fears of a relapse in his mental health investigators found “no evidence” of a risk management plan being prepared.

The report also found that no mental health agency sought to obtain information about Mr Allen’s criminal record from the police or probation service.

Allen, who had numerous previous convictions, broke nearly every bone in Mr Dunford’s face when he unleashed a sustained violent assault in the man’s Middlesbrough home.

The report said it is unclear to what extent failings in healthcare contributed to the murder of two people by Allen three years ago.

Niche Patient Safety, the independent body which was commissioned by NHS England North to carry out the investigation, concluded that services should have identified that there was a significant probability that Allen would re-offend.

The investigators said Allen, referred to as 'Mr F' in the report, was “a serial offender who was either unwilling or unable to engage in any meaningful rehabilitation programme". 

It added: "The evidence indicates that there were many deficiencies and missed opportunities by both primary and secondary health care services where important information could have been sought and shared. 

"If obtained, this information would have enabled a more accurate assessment of Allen’s risk factors and would have alerted agencies to his potential for reoffending.”

In five main findings the panel found that while Allen was registered with two primary services and attended a walk-in centre on several occasions, neither the first surgery nor the walk-in centre was able to access the second surgery’s patient records.

The panel said it took “a considerable amount of time” for the second surgery to identify that they were over-prescribing a drug called Pregablin and it was likely that Allen was misusing his medication.

The panel found that no mental health agency sought to obtain information regarding Allen’s criminal record from the police or probation service.

And despite Allen repeatedly reporting his fears of a mental health relapse, there was no evidence of a risk or relapse management plan and no agency considered the potential psychological effect of Allen’s chronic health condition on his mental health.

Niche Patient Safety made 10 recommendations for implementation by primary and secondary care services:

*Domestic violence training for primary and secondary care medical staff to improve their understanding of and responsibilities for reporting suspected and known incidents of domestic violence.

*Mental health crisis teams must obtain information from the police and probation service when a patient is identified as having a history of violence.

*The Tees, Esk and Wear Valleys Trust should review its current safeguarding policies

*Mental health staff should be considering a patient’s current housing situation as a potential risk factor.

*When a patient is registered with two primary health care services there needs to be improved information sharing.

*Secondary mental health services should be aware that patients on methadone may be registered with two primary care services.

*Both primary and secondary health care services should be considering the potential for misuse of prescribed medication in patients with health problems.

*NHS England needs to address the lack of information sharing by prison medical services.

*Primary care service should consult with the prescribing mental health clinician when they are changing a patient’s psychiatric medication.

*TEWV should obtain access to primary care notes and interview relevant GPs after incidents. They should also obtain police information if the patient involved has a criminal record.

In response to the report, Chris Stanbury, director of nursing at Tees, Esk and Wear Valleys NHS Foundation Trust, said: “Our thoughts are with the families of the victims at this distressing time.

"Sadly, we cannot change what happened three years ago and, as the report concludes, we may not have been able to prevent it.

“However, there were things that those involved in Mr F’s care could and should have done differently and we would like to apologise for our failings.

"It’s important that we learn from these tragic deaths so that we can help prevent something similar happening again.

“We have already made a number of changes to the way we work and will make sure any outstanding recommendations are actioned.”