NHS authorities have been accused of trying to cover up an incident in which two patients were attacked by another on a hospital ward after his antipsychotic drugs were stopped. The two men later died.
Details of the incident have only now become public after the leaking of a previously unpublished investigation report into the incident, which took place at St James’s University hospital, Leeds, in February 2015.
Ken Godward, 76, and Roger Lamb, 79, died after they were beaten with a walking stick by 70-year-old Harry Bosomworth.
The report, which was leaked to the Health Service Journal (HSJ), details how Bosomworth, who had been treated for paranoid schizophrenia since 1980, was admitted to the hospital with oesophageal cancer.
However, a decision was taken to stop giving him the antipsychotic drug olanzapine, despite warnings from the patient’s family, by clinicians who were more focused on his complex physical needs than his mental health.
Bosomworth was said to have been “very disruptive, shouting and swearing, abusive to all staff” during the night of 27 and 28 February. A sedative was given with the assistance of security staff, as he was said to have been kicking and punching medical staff.
Later that morning, the report said, staff discovered that he had had assaulted Lamb and Godward with his walking stick, inflicting facial injuries to the latter. Lamb was lying on the floor with a suspected, and later confirmed, fractured femur. Both Godward and Lamb died later.
Godward’s stepson, Andrew Dixon, said the family felt as if they had been “taken for a ride”.
“The trust is trying to forget about this. I think they are hoping this doesn’t get out,” he told the HSJ.
“The impression we got on that ward was that it was chaos. My view was that there weren’t enough staff. We want something put in place that is going to protect people like Ken.”
The ward where the attack happened specialises in diabetes care but often has a high proportion of older people with a wide range of medical conditions “that also present a range of challenging behaviours”, according to the report.
Despite concluding that “it has been difficult to identify a single root cause for this incident”, the report found there had been a number of contributing factors, including not listening properly to Bosomworth’s family and a “lack of assertive, structured, coordinated and integrated mental and physical healthcare”.
It said: “The decision to stop his olanzapine was taken from a narrow physical health perspective and without any reference to the impact of stopping the olanzapine on HB’s overall mental health and long-standing schizophrenia.
“We would suggest that if they had spoken to the family in more detail, they would have obtained a more accurate and comprehensive picture of HB’s mental health needs.”
It concluded: “The low level of basic knowledge of acute medical staff of the needs of people with comorbid mental health issues in acute hospital settings has been recognised as a national issue and was a contributory factor in this case.”
Bosomworth died of cancer in July 2015, according to the report.
Along with detailing numerous missed opportunities and failings in the care of Bosomworth, the report detailed more than 40 incidents of violent and aggressive behaviour on the same ward between April 2014 and March 2015. They included nurses being punched, a patient throwing a table across the room and another slamming a medicine cabinet lid on a staff member’s fingers.
Dr Nick Scriven, president of the Society for Acute Medicine, said the case would force a reappraisal of how some of the healthcare system’s most vulnerable patients were treated.
“We need a total rethink on how and where we can meet these people’s physical and mental needs, and trusts must be open and honest in the future around this area and investigate and report this type of incident openly.”
The independent review – which was jointly commissioned by Leeds Teaching Hospitals NHS trust and the Leeds and York Partnership NHS foundation trust – was completed in March 2016 but never published.
The foundation trust said it had engaged with a further review which was commissioned by NHS England.
“Once they report their findings, we will take any further action deemed necessary to maximise the learning from this case,” it said, adding that the findings of the original independent report had been shared with the families.
Sara Munro, the trust’s chief executive, said: “The trusts accepted the conclusions and recommendations from this report and has worked closely with Leeds Teaching hospitals trust since to make the necessary improvements.”
Dr Yvette Oade, chief medical officer at Leeds Teaching Hospitals NHS trust, said it had made a significant number of improvements to how it cares for patients with challenging behaviours and mental health needs.
These improvements have led to a substantial reduction in the number of incidents reported, she said.
The current NHS England investigation is taking place under the category of inquiries into a “homicide by patients in receipt of mental health care”.
The HSJ said it had been alerted to the incident by a whistleblower in the NHS, who told the journal: “The fact that this has not been reported in the press and has not been covered by a coroner’s inquest, coupled with the behaviour of the trust, suggests a cover-up for some reason.”
