Sussex Partnership NHS Foundation Trust was criticised for underestimating the risks posed by its patients and, in some cases, failing to act on threats to kill. The failings were exposed following a review of ten killings linked to Sussex Partnership patients between 2007 and 2015.
- Roger Goswell – killed his wife and himself in West Chiltington in 2007;
- Sean Iran – killed and burned his friend in 2010;
- Steven Dunne – killed Gordon Stalker, claiming he was a witch who had captured his soul, in Brighton in 2010;
- David Sole – killed Jonathan Ellison in his flat in Brighton in 2011;
- Graeme Morris – travelled to Troon from Brighton and killed his mother in 2012;
- Shane Noble – punched and kicked Chris Poole to death in Eastbourne in 2012;
- Kayden Smith – killed Jan Jansen, a Danish tourist at his flat in 2012;
- Oliver Parsons – killed Joe Lewis on Christmas Day in Brighton in 2014;
- Janet Muller – found burned to death in the boot of a car near Horsham whilst under the care of the Trust in 2015. Christopher Jeffrey Smith was convicted of manslaughter;
- Matthew Daley – stabbed motorist Donald Lock 39 times on the A24 in Findon, West Sussex in 2015.
A review of each death was commissioned by Sussex Partnership and NHS England following the stabbing of Donald Lock in 2015. Matthew Daley had been under the care of Sussex Partnership at the time. His mother had pleaded with mental health experts to have him sectioned but was ignored. A road traffic collision caused Mr Daley to become so irate that he stabbed 79 year old Donald Lock to death. He was later convicted of manslaughter on the grounds of diminished responsibility.
The review identified that both killings by Kayden Smith and Roger Goswell had been ‘preventable’ and ‘predictable’. The trust has apologised and offered condolences to the families involved. Joe Goswell, son of Mr and Mrs Goswell, has since stated that he has no doubt that the trust could have prevented the death of his mother. Furthermore, he has expressed that he was promised that changes would be implemented to prevent a similar incident but that deaths are still occurring. He has been left feeling that his mother died in vain.
In most cases, the process to assess patients was found to be inadequate and the risk posed by the service user went unrecognised or was severely underestimated. In some cases, risk assessments were just not completed or were completed incorrectly. It was also clear that in some cases, where the service user had made threats to kill, no further action was taken, for example; notifying the police or warning the person targeted. Sadly, the ‘learning’ after each killing had not always been circulated across the entire trust and there were cases of repetition in the recommendations made.
Comparison with national figures
Mental health is still an area that is under-resourced and requires vast amounts of change.
The very recent sentencing of Mr Nandap, who stabbed Dr Ensink outside his home in London just days after having been released from police custody, again led to calls for change.
Following the sentencing, Dr Ensink’s wife stated;
This is a terrible tragedy for me and for Jeroen’s daughter, and family and friends but it is not a one-off – mental health homicides keep happening again and again… If such tragedies keep occurring, why has there not been concerted action to address this?’
Julian Hendy, of campaigning charity Hundred Families, also echoed her call for an inquiry and highlighted the increasing issue of mental health homicide;
‘Dr Ensink was just one of the more than hundred victims of mental health homicides in Britain each year, and our research shows the numbers are increasing…’We are deeply concerned that seriously unwell people are not getting the diagnosis and treatment they need, which is leading to more and more tragedies like this.’
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