Healthcare Inspectorate Wales publishes findings of review into Tremorfa homicide

A report into a homicide carried out by a mental health service user in the Tremorfa area of Cardiff in June 2009 has “highlighted concerns in relation to the adequacy of the care and treatment” provided to the user.

A review by Healthcare Inspectorate Wales (HIW) concluded that Leyton Williams fell through the system after leaving prison due to a “breakdown in communication between all agencies”.

Chief Executive of HIW, Dr Peter Higson, said: “It is clear from our review that Mr Williams had a history of violence and mental illness. He was difficult to engage with and consistently denied that he had mental health issues and was therefore unlikely to seek help when his mental health deteriorated.

“Sadly a breakdown in communication between statutory agencies meant that following his release from prison in September 2008 Mr Williams’s mental health issues went unmonitored.”

Commenting on the HIW report Peter Martin, National Policy Co-ordinator at the mental health charity Hafal, said: “Sadly, yet again we see a failure in communications between services resulting in someone with a mental illness falling through the net. Organisations providing mental health services need to improve their systems, get their act together and start to talk to each other.

“There needs to be improved links and liaison between different agencies, particularly between criminal justice agencies and health and social care providers. It should act as a warning sign when people clearly in need of a service refuse or are reluctant to engage with those services, and all agencies that have been involved need to be kept informed and kept up to date when a person enters one part of the system.”

To read the HIW report please visit: