In February 2004, on the day he was due to be admitted to a psychiatric hospital, mentally ill Leslie Gadsby killed his father Arthur with a hammer. Less then two years later, in December 2006, he was conditionally discharged from hospital by a mental health review tribunal, with the agreement of hospital managers and Mersey Care NHS Trust.

In March 2010 he fatally stabbed his mother.

Today a highly critical independent investigation has been published into his care, and the failings that have been uncovered are truly shocking.

Following his release Gadsby was meant to be monitored 24 hours a day, but the report found ‘unacceptable’ planning failures ‘ left him  to regulate his own activities and set his own boundaries.’

There was no system to detect a relapse in his mental state, meaning those looking after him consistently reported back that he was doing well.

He had apparently not properly taken his anti-psychotic medication for years.

Astonishingly just five months after brutally killing his father, his risk of aggression and violence was deemed ‘low’ by mental health staff, despite him suffering “paranoid ideas about his neighbours and members of his family.”

There was a serious causal link between the lack of care and the death of his mother. Had he been subject to ‘robust supervision’ the risk he would have killed his mother would have been ‘substantially reduced’.

The report further found those looking after him

• Didn’t diagnose him properly
• Didn’t keep proper records
• Didn’t do proper risk assessments
• Didn’t follow national guidelines and
• Didn’t monitor him effectively in the Community

It said: “There were serious failures in the implementation of the terms of Mr. Y’s conditional discharge. This meant that the conditions put into place by the Ministry of Justice to protect the public were rendered ineffective.

and

“The discharge process did not address in sufficient detail either the needs of Mr. Y or the continued safety of the public”

Mental health staff knew Leslie Gadsby could be extremely dangerous when unwell, yet have failed miserably to keep both him and his mother safe.

If mental health services can’t care effectively for seriously ill people who have killed before, what confidence can we have in their care for anybody else?

The problems uncovered in this report are not new – very similar failings in basic mental have been uncovered in inquiry reports for the last twenty years, and yet still continue today. There is little evidence that mental health services are learning from these tragedies.

There should have been an independent inquiry into the circumstances around the death of Arthur Gadsby in 2004, but health managers at the time didn’t bother to conduct one.

Had they done so, and lessons had really been learned, it’s very possible that Edna Gadsby would still be alive today.