Case Study: NHS North West

‘Not appropriate or necessary’ – How NHS North West is compromising patient and public safety

NHS North West is failing to properly investigate large numbers of homicides by the mentally ill, leaving patients and the public at risk

Mental Health Homicides in the North West

People in the North West of England have the highest rate of long term mental health problems in the country.

There have been at least 68 murders by people with mental illness in the region over the last 15 years. As not all cases are reported, this figure is likely to be a considerable underestimate.

Some of them have been particularly horrific.

  • In March 2003, in Blackpool psychotic John Jarvis fatally stabbed his wife Patricia, removed her heart then stabbed and cut the throats of his two sons Stuart (8) and John (11). He said he was unhappy about his wife smoking.
  • Three months later in Manchester, Aisling Murray, who had been released from a psychiatric hospital just a month earlier, stabbed her five year old daughter Chloe, more than 50 times in what was later described as a ‘horrific ritual murder’.
  • In July 2003, Daniel Rogerson, a mentally ill man with a fixation with knives, fatally stabbed his elderly neighbour Richard Hodgson then buried him in the back garden. Rogerson’s mother said she had made ‘frantic attempts’ to get him help but to no avail.
  • In Liverpool in February 2005 Robert Mills, a paranoid schizophrenic bludgeoned his parents to death with hammer & tried to burn their bodies. He said he was upset because they’d decided to redecorate his bedroom.
  • In August 2005 paranoid schizophrenic Anthony Barnwell was babysitting for a friend when he said the television had told him the child was Judas and needed to be ‘wiped out’. He stabbed six year old James Brennan 72 times. Barnwell then killed the family dog.
  • In Manchester in December 2008 paranoid schizophrenic Eric Cruz, repeatedly stabbed his neighbour, Patrick McGee, then sawed off his head and dumped it in a wheelie bin. He said he’d heard voices commanding him to kill and obeyed them.

Strategic Health Authorities have to commission inquiries

When a recent mental health patient kills someone the government requires the local Strategic Health Authority to hold an independent inquiry.

It’s not supposed to be optional.

Inquiries are designed to ensure public and patient safety and, as far as possible, to prevent such killings from happening in future. They are an opportunity for local mental health trusts to learn from their mistakes.

Because health authorities were failing to commission inquiries properly, government guidance to health bosses had to be restated three times over the last four years – in 2005, in 2007 and in 2008. The National Patient Safety Agency even spelled out exactly what was required in its ‘Best Practice guidance’ on Independent Investigations in February 2008.

Health Authorities have been formally told three times that they have to commission proper inquiries – yet some of them still aren’t bothering. And one of the worst offenders is NHS North West.

Half of mental health homicides not properly investigated

Buried away in the minutes of the board meeting of NHS North West Strategic Health Authority for September 2009 is a review of all the mental health homicide cases in the North West between 2002 and 2006 which haven’t been properly investigated. It’s entitled ‘Promoting Patient Safety’.

It found there had been 42 mental health homicides in the North West between January 2002 and July 2006.

Of these 42, the review found only a third (14) had received a full independent investigation. Seven were found to fall outside the government criteria (as they may not have been ‘recent’ patients). This left 21 killings by mental patients (ie half) which had not been properly and independently investigated.

Flawed review

The Strategic Health Authority commissioned Colin Dale to lead the ‘Promoting Patient Safety’ review.

Although the review was supposed to be independent, Colin Dale is a non-executive director of one of the local North West Mental Health Trusts under investigation – 5 Boroughs Partnership Trust based in Warrington.

Internal Trust documents reveal four mental health homicides were committed by 5 Boroughs patients between 2002–2006.

Having a project leader from a local Trust with so many mental health homicides in the period under consideration raises serious questions about the overall independence of the project.

Mr Dale’s role as a director of 5 Boroughs Partnership Trust is not mentioned in the Promoting Patient Safety review.

Mr Dale with the SHA, appointed six mental health professionals to a panel to help review the cases. 1

They looked at the 21 cases which hadn’t been investigated properly and obtained 19 internal reports from the mental health trusts directly involved in the cases. (The other two couldn’t be found).

The problem of Internal Reports

Internal reports, by their very nature, aren’t necessarily the best or most accurate guide to problems in the health service. They are often not very rigorous (as they are investigating themselves); they are held in secret; they don’t publish their findings and they don’t tend to be particularly critical of the service that is paying their salaries.

It has been suggested privately within NHS North West that some of these internal reports were ‘not fit for purpose’.

North West review didn’t meet best practice

Despite these potential problems the ‘Promoting Patient Safety’ inquiry panel just read the local internal health services reports, made a few comments and declared themselves satisfied they had discovered all they needed to know.

Which was curious because

  • they didn’t question any of the original staff
  • they didn’t review any of the original patient case notes
  • they didn’t seek additional information from the police or other agencies
  • they don’t appear to have spoken to any of the families concerned

A proper independent investigation, according to the National Patient Safety Agency Best Practice guidance for Independent Investigations would have done all these things.

Further investigation ‘not appropriate’

The review panel identified some recurring themes in the internal reports and sought assurances from the trusts that ‘lessons had been learned’ and that recommendations were being implemented.

The mental health trusts, not unsurprisingly, confirmed that everything was indeed now in hand.

Despite the obvious problems with this approach, the ‘Promoting Patient Safety’ review panel decided to advise NHS North West not to commission proper independent investigations into any of these 21 killings as government guidance requires.

It was, they said, ‘not appropriate or necessary’.

Holding independent inquiries now, they argued, would be distressing for the families; staff involved in the cases would be difficult to find so long after the event; the killers hadn’t given consent to see their medical records; and that anyway the cursory investigation by the review team was fully sufficient to identify any problems.

NHS North West readily accepted the recommendation and declared a vote of thanks to Colin Dale and his team.

Catalogue of Failure

The ‘Best Practice’ guidance from the NHS National Patient Safety Agency says mental health inquiries are supposed to be transparent, open, inclusive, timely and proportionate.

The exercise in the North West was none of those things.

  • The individual internal inquiry reports have not been published.
  • The 21 cases have not been identified by date, by location or even by mental health trust.
  • There is no information whether any particular trust was particularly bad (or good), or whether any particular members of staff were involved in numerous incidents. There is no comment from the families of victims or carers.

There has been no effective public scrutiny of the inquiry process whatsoever.

The families of the victims appear to have been completely ignored.

People in the North West deserve better. They deserve the best possible care, with the safest mental health system possible and at the moment they don’t appear to be getting it.

1. One of them apparently was the author of ‘Get slim and stay slim, The Psychology of Weight Control’


Highest rate in the country From NHS North West. Board Meeting 2 Sept 2009 – (page 12)

Government Guidance – 2005 link to pdf

link to pdf


NHS North West September 09 Board Minutes at

Promoting Patient Safety Report

Colin Dale’s Non executive director 5 boroughs partnership homepage

5 Boroughs mental health trust homicides from

Internal documents also reveal Colin Dale was aware of the potential conflict of interest

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