HIW report on Caerphilly homicide raises concerns about care and treatment

A Healthcare Inspectorate Wales report published today has highlighted serious concerns in relation to the adequacy of the care and treatment provided to Martyn Davies, a service user who carried out a homicide in the village of Llanbradach, Caerphilly in March 2009.

Concerns highlighted in the report about the care and treatment of Mr Davies (referred to as Mr H) include that:

  • There was a great deal of evidence which indicated that in a crisis, Mr H was likely to harm himself or others.
  • The homicide may well have been preventable.
  • There were many shortcomings in the care and treatment of Mr H over a number of years, and failings by various health and social care organisations and care providers.
  • Opportunities were missed during January and February 2009 to admit Mr H to hospital either as an informal patient or under the Mental Health Act.

In response to the report, Aneurin Bevan Health Board and Caerphilly County Borough Council have published an Action Plan which identifies how the findings can be addressed. Proposed actions include:

  • Developing a joint integrated transition pathway from children’s to adult services that fully details the roles and responsibilities of each service and the actions to be taken during transition.
  • Ensuring all teams have in place information sharing protocols and guidance that clarifies requirements and timescales on the sharing and transfer of information.
  • Providing all patients subject to 117 aftercare planning for discharge from secure accommodation with an NHS bed or alternative service.

Alun Thomas, Deputy Chief Executive of Welsh mental health charity Hafal, said: “This is a shocking report detailing quite incredible failings in services, most particularly in the indefensible decisions made by the specialist hospital involved. We will be watching both the Aneurin Bevan Health Board and Caerphilly County Borough Council very closely to see that they take the actions identified in their Action Plan. We also hope that if implemented properly, the new Welsh mental health legislation which comes into effect shortly and which focuses on giving service users rights to timely and effective care and treatment will play a major part in preventing such tragedies as this happening in the future.”

Chief Executive of Healthcare Inspectorate Wales, Dr Peter Higson, said: “Our review has highlighted many concerns in relation to the care and treatment provided to Mr H over a period of many years. In particular, Mr H’s discharge from hospital in October 2008, following a long period of detention under the Mental Health Act was not managed properly. His discharge was followed by a series of missed opportunities to provide better and more structured care to Mr H. While it is clear that the Assertive Outreach Team tried to provide support to Mr H during the weeks leading up to the tragic event, the service was only available during weekdays and was therefore not sufficient to meet Mr H’s complex needs.”

To read the report, click here.