Thursday, May 07, 2009

NHS trust apologises for 'under-treating' a mental patient who went on to kill a pregnant woman

Basically, they just wanted rid of him

A mental health patient stabbed a pregnant stranger to death after a string of failures in his care, a report revealed. Benjamin Holiday, a law student, killed mother-of-five Tina Stevenson, 31, in a random attack a day after missing his medication.

An independent investigation found his mental health problem was 'under-treated' and his condition should have been 'more assertively managed'. A decision by a social worker not to detain him just weeks before the killing was a vital 'missed opportunity'. Humber Mental Health Trust has now apologised to Miss Stevenson's family.

The 31-year-old had been seven months pregnant with twins when she was killed. The unborn children also died.

Holiday, now 28, was a talented undergraduate until experiments with cannabis and then ecstasy are believed to have caused his mental illness - forcing him to drop out of university. He was diagnosed as suffering from paranoid schizophrenia and was 'in and out' of psychiatric hospital for four years.

In November 2004 psychiatrists decided he was well enough to be released from a secure hospital unit after two weeks' treatment and he returned home to live with his mother Christine, taking medication every two weeks. The day before the killing a community nurse arrived at the family home in Hull by appointment to give Holiday his regular injection, but he was not there.

On January 5 2005, Holiday stole a knife from a store and stabbed Miss Stevenson as he walked home. She had been to a hospital ante-natal clinic that morning and was walking near her home when she passed him. Holiday, who had previously complained of hearing voices in his head telling him to kill, turned around and stabbed her once in the back before running off.

In 2006 he was given an indefinite hospital order after admitting manslaughter by reason of diminished responsibility.

The independent report written by NHS Yorkshire and the Humber listed a series of failings in his treatment. It said Holiday was able to 'abscond and absent himself from inpatient care too easily' and his final admission in November 2004 was 'a missed opportunity to compulsorily detain him'.

Detailing his years of treatment and problems, the report revealed how Holiday told a nurse in 2002 he thought about killing his friend and felt he could have raped a woman he went on a date with. He was admitted to hospital the following day and discharged days later.

In November 2004 he escaped after being sectioned and a consultant psychiatrist requested his social worker make a formal application for his longer term 'detention' on his return. But when he returned Holiday seemed 'calmer', the social worker decided against making the application and he was released.

The inquiry concluded Holiday's consultant psychiatrist, who had an excessive workload, was not to blame. It recommended a number of changes to procedures and staffing.

Yesterday Holiday's mother Christine said: 'It is clear mistakes were made in my son's care. There was a lack of communication, a lack of accountability, and records were not shared. 'This meant people did not realise how ill my son was and so he didn't always receive the most appropriate care.'

The same NHS trust also apologised to the family of Ivy Torrie, 82, who was killed by her mentally ill son, Michael, in Pocklington, East Yorkshire, in 2003. A separate report yesterday said the root cause of Torrie's actions was the 'rapid reduction of medication and the way this was managed in the absence of a risk assessment'.


Australia: NSW government refuses to reform its disastrous ambulance service

The untouchability of government employees once again

THE controversial head of the NSW Ambulance Service will not be sacked despite a damning parliamentary inquiry that found he had presided over a decade-long failure to deal with bullying and harassment within the organisation that led to at least nine suicides.

The Minister for Health, John Della Bosca, said the tenure of the ambulance chief executive, Greg Rochford, had been reviewed in January three months after an upper house committee called for an urgent investigation into his performance.

In announcing the Government's response to the 45 recommendations made in the report, Mr Della Bosca said yesterday he was committed to a statewide "culture change and improvement program" to end endemic bullying in the service. However he refused to take direct responsibility for the service or the performance of its chief executive.

Mr Rochford, whose resignation has been called for repeatedly by the Health Services Union, will keep his job, although a committee of long-time current and retired NSW public servants will be appointed to oversee his efforts to resolve disputes and address workplace behaviour. And Mr Rochford will continue to be responsible for the management of senior ambulance executives, despite the report finding they were a "nepotistic old boys' club" who swept claims of bullying and harassment under the carpet for 10 years.

Phil Roxburgh, whose revelations about bullying at the Cowra ambulance station sparked the inquiry, said Mr Rochford and other senior executives should have been removed. "To find out these people are still in the same positions, offering no more than lip service [to anti-bullying policies] is very disheartening and disappointing," said Mr Roxburgh, who is now manager of the Moruya ambulance station. "I do not want to see our only chance for a change in culture blown."

A paramedic, Christine Hodder, the first woman to work at the Cowra ambulance station, took her life in April 2005 after years of bullying. Mr Roxburgh, her former manager at Cowra, went on stress leave after he was harassed for supporting her.

Mr Della Bosca said many of the recommendations from the inquiry were already being dealt with by the Government including the appointment of an extra two investigation staff to ensure serious matters were dealt with rapidly, a "healthy workplace manager" to deal with grievances and a compulsory "respectful workplace training" program for all staff. "Change on this scale will always create workplace tensions and it's a credit to the workforce that the healthy workplace initiatives are being embraced," he said.

The committee chairwoman, Robyn Parker, a Liberal member of the Legislative Council, said some issues raised in the six-month-long inquiry, such as wages and conditions, had since been resolved following a hearing in the NSW Industrial Relations Commission. However, the Government had not explicitly accepted the majority of recommendations in its response but used "weasel words" to claim issues were already being addressed, without any evidence of change.

Ms Parker said she had been getting numerous letters from people saying "nothing has changed, the culture and the environment is as toxic as it was during the inquiry". "Unless there is a massive cultural change starting from the very top of the service, how can officers trust the Rees Government?"


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