Woman killed by mentally ill husband 'died in vain' amid trust failings says son
A man has said he believes his mother "died in vain" because a mental health trust failed to learn lessons and prevent other killings.
Joe Goswell's father, Roger, murdered his 63-year-old mother, Susan, at the couple's home in West Chiltington, West Sussex, in December 2007. Mr Goswell, who was mentally ill, had become obsessed with the fact that his wife was not a virgin when they married 46 years earlier.
Calls were made to police about the threat to Mrs Goswell's life in the weeks before her death and Mr Goswell, 66, was discharged from the Priory psychiatric clinic days before he killed her.
An investigation into the role of Sussex Partnership NHS Foundation Trust found that, while Mrs Goswell's death was predictable, the trust could not be blamed for not having prevented it.
However, it heavily criticised staff for failing to take appropriate action over Mr Goswell's repeated threats to murder his wife.
It said Mr Goswell was "able to manipulate his treating team into not detaining him under a section of the Mental Health Act by staying as a voluntary patient and by claiming his plans to kill both his wife and himself were a mere fantasy".
A new review into 10 killings by and of patients at Sussex Partnership has criticised the trust for failing to learn lessons from previous incidents.
It found the trust "severely under-estimated" the risk posed by mental health patients and often only viewed them as victims rather than potential abusers and murderers.
It also failed to include the views of families, some of whom pleaded for help, and did not always send people with signs of psychosis to specialist services.
Joe Goswell told the BBC Radio 4 Today programme that he did not believe lessons had been learned from his mother's death.
He said that when NHS failings were highlighted at her inquest, Sussex Partnership had apologised and "said that things would change and they would make changes to prevent this happening again".
He added: "Here we are, nine years on, still people are being murdered by mental health patients. I feel that my mother died in vain because where we thought as a family (that) notes would have been taken and things improved ... and here we are having the same conversation as what was said across the table at the inquest nine years ago."
Colm Donaghy, chief executive of the Sussex Partnership NHS Foundation Trust, apologised to Mr Goswell for the fact he had not been told a new report was coming out, adding: " At the root of the issue is obviously the fact that we need to ensure that we have a positive culture and an organisation that when these really tragic events happen we put in place changes that reduce the likelihood of them happening again."
The new review was ordered after the death of Donald Lock, who was stabbed 39 times by Matthew Daley on the A24 in Findon in July 2015.
Daley admitted stabbing 79-year-old Mr Lock to death, claiming diminished responsibility, and was convicted of manslaughter in May.
Lewes Crown Court heard Daley's family had pleaded with the NHS to have him sectioned.
Sussex Partnership has admitted it "got things wrong" and should have carried out a formal assessment for Daley.
In the new review, investigators found that in seven of the killings, there was criticism of how the the NHS trust assessed the risk posed by its patients. It regarded two of the deaths as predictable and/or preventable.
Processes were reported to be "inadequate and the risk posed by the service user went unrecognised or was severely under-estimated".
In some cases "risks assessments were not completed or were completed incorrectly" and "risk management plans were not completed".
It added: "Sometimes service users made threats to kill others but no further action, for example informing the police or warning the person threatened, was taken."
The report said learning after each killing was not always taken up across the trust and there was some "repetition" in the recommendations made after each one.
Shadow minister for mental health and social care Barbara Keeley said the report was "disturbing".
She added: "It is very worrying that, in some cases, this large NHS trust took no further action after service users threatened to kill others, including not informing the police, warning the person threatened, or triggering a management plan."