‘Serious omission’ in murder case
Thursday 31st October 2013, 5:21PM GMT.
Mental health officials failed to tell a man who was killed by his former partner that he was at risk, an independent report has found.
Brian Maddock described murderous thoughts about Michael Naylor to his psychiatrist but Manchester Mental Health and Social Care NHS Trust failed to warn Mr Naylor he was at risk, the Health and Social Care Advisory Service report concluded.
The report said that a “serious untoward incident of some kind was foreseeable”.
Five years before killing his former partner Maddock told the psychiatrist h e had taken a sharp knife from the kitchen and a rock from the garden to “smash his friend’s head and afterwards slit his throat”, the report said.
Maddock, who was jailed for life with a minimum term of 15 years in May 2011 after being found guilty of murder, told his psychiatrist he planned to harm Mr Naylor but changed his mind, the report found.
The psychiatric patient also described how he had repeatedly stabbed a friend with a carving fork seven years previously.
Five years later, on 21 November 2010, Maddock stabbed Mr Naylor to death after an argument took place in the Manchester home where the pair still lived together, the report said.
The report concluded that Maddock’s thoughts in relation to causing Mr Naylor harm “should have been made known”.
But the Trust could not have actually prevented Mr Naylor’s death, the report’s authors said.
” It was the conclusion of this investigation that a serious untoward incident of some kind was foreseeable based upon Mr Z’s (Maddock) past history and behaviour,” they said.
“It was evident that his behaviour was impulsive and that he had anger control issues.
“He was still experiencing flashbacks relating to his post traumatic stress disorder symptoms which were not controlled by the therapeutic interventions that he received.
“This i nvestigation concluded that all known risks regarding Mr Z’s thoughts and plans in relation to causing Mr Y (Mr Naylor) harm should have been made known to Mr Y and that the Trust had a clear duty of care to have ensured this took place. This was a serious omission.
“However it was not possible to establish a causal link between Mr Z’s mental illness and his decision to kill Mr Y. Therefore it was not possible to establish a casual link between any act or omission on the part of the Trust.”
Dr JS Bamrah, interim medical director of Manchester Mental Health and Social Care Trust, said: “We would like to offer our sincere condolences to the family of Mr Y.
“The Trust undertook a thorough investigation following Mr Y’s death in November 2010 and, as a result of our own and the subsequent independent investigation, implemented a number of actions to improve our processes around the care provided to patients presenting in a similar way to Mr Z.
“The Trust’s central objective is to ensure the safe and appropriate care of some of the most vulnerable members of society. We are continually reviewing and improving services to reflect lessons learned and ensure that similar tragedies can be avoided in the future. It is about continuous improvement, learning and putting the patient and those closest to them at the centre of what we do.”
Mr Naylor’s sister Barbara Venner said: ” It is clear from this report that there have been numerous failures in the Mental Health system in Manchester, failures that I believe cost my brother Michael, his life.
“I believe the main mistake in this case was the failure by the Trust to inform the police and my brother of the threat to his life.
“My brother was never given the information about the threat to his life. He was never afforded a choice, his right to life was disregarded, and he was most certainly, in my opinion, never given the respect he deserved.
“I believe if Manchester Mental Health Trust had done their job properly Michael would still be alive today.
” Failure to disclose the threat of serious harm to a named individual should become punishable by law. The law needs to be changed.
“This would serve to protect the professional, the public, the victim and the perpetrator alike.”
She added: ” I would like to pay tribute to my brother Michael, who died in such traumatic circumstances.
“He is greatly missed by his family, he was a good man, he made us laugh, he was caring, kind, generous and sincere. He was my very dear brother and my best friend.”