Death of policeman was 'preventable' says report

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The Independent Online

The death of a policeman stabbed to death by a paranoid schizophrenic could have been prevented if he had been treated suitably, an independent report found today.

Tennyson Obih was jailed for life last March after he was found guilty of murdering Pc Jon Henry in Luton in June 2007.

The policeman was stabbed twice as he tried to arrest Obih in George Street, Luton, on June 11, after he stabbed window cleaner Stephen Chamberlain.

The paranoid schizophrenia was under the care of the former Bedfordshire and Luton Mental Health and Social Care Partnership NHS Trust (BLPT), but he had stopped taking his medication and was often not at home when community nurses were called.

Today an independent report from Verita, commissioned by NHS East of England, said the starting point for the tragic case was a decision to close an early intervention service that Obih had previously used to save money.

Report author Lucy Scott-Moncrieff said they found a series of "management and clinical failings" starting from that decision.

She said: "The cumulative effect of these failings was that at the time of the incident Mr Obih's illness was untreated and his well-being was effectively unmonitored.

"We find therefore that the incident might not have occurred if he had been suitably treated and might therefore have been prevented."

She said they found no evidence that Obih's violence could have been predicted.

"The starting point of this tragic case was the decision to close an important service to balance the trust's budget in line with its reduced allocation from the PCT," she said.

"In the current economic climate, it is likely that other trusts may find themselves in a similar position.

"If community teams are to be re-configured, managers and clinicians need to work together to ensure that this is done safely."

Ms Scott-Moncrieff said Obih, who was diagnosed with schizophrenia in June 2004, had no history of violence. He was under the care of BLPT.

Between February and July 2006 he was an in-patient at a recovery unit in Luton, then moved into his own accommodation under the care of the Luton Early Intervention Team.

But in September 2006, as part of a programme of cost savings required by Luton Teaching Primary Care Trust, the early intervention service was closed, she said they found.

She said the service provided a greater level of care and supervision than could be expected of a community mental health team - which typically carried double the case load.

Obih was then transferred to Luton South East Community Mental Health Team - he was assessed twice for transfer to an "assertive outreach team" for more intensive support but was not thought to need it.

Obih received "considerably less" support from the mental health team care coordinator and was seen 16 times in four months, compared to 36 times in two months with the early intervention team, the report found.

After this, he stopped attending a day care service, and in December 2006 it was found he had stopped taking his oral antiphsychotic medication.

In January 2007 he also refused to acept a fortnightly injection.

"Between January and June 2007 he took no medication for his mental illness, and met his care co-ordinator only four times," Ms Scott-Moncrieff said.

"The care co-ordinator told his community mental health team colleagues that Mr Obih was not taking his medication, but a professionals meeting or case review was not held to assess what impact this was having on his mental state.

"At his trial the judge accepted that Mr Obih's behaviour on June 11, 2007 was affected by his untreated mental illness to some extent.

"We identified a series of management and clinical failings starting from the decision to close the early intervention service."

She said they made a number of findings: they found the decision to close the early intervention service was wrong and senior trust managers failed to ensure the agreed transfer process between that and other services was followed.

The community mental health team could not offer Obih the level of care he was receiving previously and "could and should have done more for him", she said.

"The inadequacies in care planning and risk assessment and management were not simply technical beaches of detailed trust policy, but evidence of individual and team poor practice within Luton South East Community Mental Health Team."