Harry Bosomworth suffered a severe relapse of paranoid schizophrenia on a ward at St James’s Hospital in Leeds amid a month of confusion over treatment for his condition.
Patients Ken Godward, 76, and Roger Lamb, 79, died within days after he assaulted them with a walking stick on February 28, 2015. Mr Bosomworth, 70, died three months later from cancer.
The independent report ordered by NHS England found the incident was “probably preventable” and the risk of violence predictable although its extent was not.
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The findings published today (Dec 18) contrast with those of coroner Kevin McLoughlin who found staff could not have predicted or prevented the attack.
The expert review, which was not considered at the inquest which finished on Monday, is critical of an internal investigation ordered by NHS officials in Leeds which made 10 recommendations for change.
Making a further 21 recommendations, it found the root cause was a lack of understanding between hospital and mental health staff about the impact of a relapse and the risks, leaving Mr Bosomworth largely untreated for four weeks.
The report said the probability of violence for 10 days prior to the attack “was high enough to warrant action by health professionals to try to avert it” although investigators said they did not believe the extent of violence used could have been predicted.
The report found Mr Bosomworth’s physical health needs “were prioritised above his mental health needs”.
It said he should have been given a drug for his illness as it was known he was at high risk of relapse without it, while his stepdaughter had persistently warned staff about the risks.
It found steps to prevent a deterioration in his condition could have been taken eight months earlier as his health was worsening but he was not referred for help in the community.
There were delays getting him expert mental support four weeks before the attack and he could have been nursed separately with extra observations by staff in the hours prior to the tragedy.
The report reveals there had been a series of violent incidents on the ward over 11 months before the incident including patients brandishing weapons, crockery and glass being thrown and other attacks by patients on each other.
It found the internal investigation left unanswered questions about the attack and Mr Bosomworth’s care.
The families had been rebuffed in a process which was “unnecessarily distressing” for them.
Tonight, Mr Holdsworth’s stepson Andrew Dixon said the three families were “very disappointed” the report was not considered at the inquest.
“It’s highly critical and it needed to be put as evidence,” he said.
They still had questions and were not convinced the NHS would learn the lessons from the case.
“It’s changed our lives – they’re still on hold,” he said.
Yvette Oade, chief medical officer at Leeds Teaching Hospitals NHS Trust, said it would implement the additional recommendations.
“We believe it is very important to the families involved in this case that we show we have learned lessons from these tragic circumstances and that we ensure the care we provide is safe and effective,” she said.
Sarah Munro, chief executive of Leeds and York Partnership NHS trust, which provides mental healthcare at St James’s, said the trust did not believe staff could have predicted the incident.
“Our view on predictability and preventability is based on extensive research on incidents of violence amongst people with serious mental illness, which is much lower than that found in the general population.”