The killing of Llanbradach pensioner Gwen Poole by a man suffering from schizophrenia was ‘preventable’, according to a new report.
Martin Davies, 23, stabbed 66-year-old Mrs Poole with a bread knife near her home in March 2009 after he heard “voices in his head”.
Davies, of New Tredegar, later admitted manslaughter on the grounds of diminished responsibility.
The Welsh Government commissioned Healthcare Inspectorate Wales (HIW) report has found that failings in Davies’ care meant the killing was preventable.
The report, which refers to Davies as Mr H, reads: “We firmly believe that the homicide may well have been preventable. Our review has highlighted many shortcomings in the care and treatment of Mr H and failings by various health and social care organisations over a
number of years.
“This catalogue of failings includes issues of service provision and delivery, and the individual actions of particular clinicians and care providers.”
Responding, NHS Wales Chief Executive David Sissling said: “This is a very serious and deeply distressing situation for all involved, and my thoughts are very much with the families of those affected.
“It is important that when such tragic events occur, we investigate thoroughly, identify any necessary changes and put in place measures to reduce the risk of such incidents happening again.
“We therefore commission an independent investigation following every homicide, if the perpetrator has been in contact with mental health services in Wales within the last 12 months.
“Such reviews may reveal failings in the level of service provided and it would appear that, in this case, there were significant shortcomings in the support, care and treatment afforded to Martin Davies.
“On behalf of the NHS and social care services in Wales, I would like to apologise to everyone affected by this tragedy.”
The report highlights how Davies suffered problems with Asperger’s Syndrome, Schizophrenia and drug and alcohol abuse from a young age.
It is critical of the way Davies was discharged from a private mental health hospital six months before he killed Mrs Poole.
When he left Cygnet hospital near Weston-super-Mare in Somerset, he was driven back to South Wales and left in the foyer of a homelessness office with his belongings.
The report said: “We are particularly concerned with regard to the circumstances surrounding Mr H’s discharge from Cygnet hospital. The rationale for his discharge is questionable and the fact that health and social care staff accepted it was appropriate for a vulnerable young man who had spent more than a year detained in hospital to be discharged to a homelessness office is indefensible.”
Davies was admitted in August 2007 to Cygnet, with whom Gwent Healthcare NHS Trust had a contract to provide placements.
The inspectorate report said that in July 2008 a risk assessment of Davies by nursing staff at Cygnet recorded his risk of violence to others as “significant”.
A further nursing report at Cygnet in September 2008 advised “the risks to himself and others would be extremely high if he were discharged into the community without an intense level of community support”.
He was discharged in October 2008 after a consultant ruled he showed “no evidence of schizophrenia”. Later the same day he was placed by the Caerphilly homelessness team in a B&B hostel.
The report said: “There was a great deal of evidence which indicated that in a crisis Mr H was likely to harm himself or others. He had attempted suicide in the past and had repeatedly admitted to having auditory hallucinations. His psychotic symptoms were compounded by his alcohol and drug misuse.”
Cygnet Health Care said: “We accept the report’s findings and in line with its recommendations we are already working with the Welsh statutory bodies to ensure that patient discharge planning is as rigorous and robust as we can possibly make it.”
Llanbradach ward councillors Colin Mann and Rob Gough said: “The death of Mrs Gwen Poole was a tragedy, in particular for her family, but something which has also had a deep effect on the whole community of Llanbradach.
“The HIW report has pointed to past failings in the system. We recognise that measures have been put in place since the incident which are addressing these issues.
“Nothing can bring back Mrs Poole but we fully support any changes in the care system that will ensure that this sort of thing doesn’t happen again.”