THE ‘inadequate discharge’ from a mental health unit has been identified as a ‘significant issue’ that contributed to a schizophrenic man killing his father.
The decision to discharge Barrow man Jonathan MacMillan into the community was ‘flawed’, a Joint Domestic Homicide Review and independent mental health homicide investigation found.
The review – commissioned by NHS England – said ‘no consideration’ was given to the potential risk to Jonathan and his family when he was released from the Cygnet Health Care unit in Maidstone, Kent on June 13, 2019.
He would go on to fatally stab his father at their home in Provincial Street, Barrow just five days later.
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In May 2019, Jonathan was transferred to the male Psychiatric Intensive Care Unit (PICU) Cygnet Health Care in Maidstone after concerns were made about the risks he had presented.
He had previously been sectioned in Carlisle then transferred to the Dova Unit in Barrow before his move to Kent.
Findings from the review assert that the assessments completed while Jonathan was detained at Cygnet Health Care were inadequate, stating: “In our view, psychosocial education should have been provided for [Jonathan] and his parents in understanding the nature of his diagnosis, how his family could support him, what could be expected in terms of recovery, and how medication may affect him.”
Jonathan’s risk was not adequately reviewed in ward rounds and incidents were not discussed, for example his aggressive behaviour when staff declined to give him extra food, the review said.
Expiry date of sectioning 'incorrectly logged'
Due to an administrative error the expiry of date of Jonathan’s sectioning was incorrectly logged within the internal systems at Cygnet Hospital Maidstone as June 14 2019 instead of July 14 2019.
The review found the origin of this error appears to have been made by an administrator assistant. After the error was made, there was no secondary scrutiny or checking of the dates by more senior staff.
Regardless of the error, the responsible clinician expressed the view that Jonathan had made sufficient clinical improvement in his mental state and his risk had reduced sufficiently for him to be discharged from hospital on June 13 2019.
However, findings from the review identify other areas which should have been considered by the health care unit, including:
- evidence to indicate residual psychotic symptoms
- patterns of increased hostility and risk towards his family following his sectioning
- limited engagement with staff and therapies
- exhibiting hostile behaviour towards staff and making female staff feel uncomfortable, even the day before discharge.
Planning for discharge was 'extremely limited'
The review points towards evidence indicating that the planning for discharge was ‘extremely limited’.
It said the perspective of the family regarding his continued detention was not adequately considered.
Although Jonathan was discharged to his mother’s house, she was not involved in discussion of the discharge plan arrangements for supporting him in the community.
Jonathan’s mum spoke to his care co-ordinator about the discharge plan, who said that they would complete an incident report about the ‘unplanned’ and ‘unsafe’ discharge.
The care co-ordinator told Jonathan’s mum to let the team know when he arrived back in Barrow and that they would complete a 48-hour review.
They also checked that she had the contact numbers for the out-of-hours services should she need their support, the review said.
'Inadequate discharge' contributed to homicide
There was also no consideration of Jonathan’s past risk behaviour towards women upon discharge and Cumbria Constabulary were not notified when he was discharged back to his mother’s address as had been directed in the Multi-Agency Risk Evaluation (MARE) action plan.
As well as this, the ‘Notification of Discharge’ document signed off jointly by the Ward Manager and Ward Specialty Doctor did not state any specific discharge plan for ongoing care and support in the community.
The review further requestioned the decision of Cygnet Health Care to rescind Section 3 of the Mental Health Act and discharge Jonathan from the unit based on just three weeks’ contact with a patient who had a considerable history of violence.
Jonathan was described by his mother as very bright; he was good at Maths and did well in GCSEs and A levels. He did not have any idea what he wanted to do after school and did not have any plans for the future.
He was a bit of a ‘loner’, who liked his own company and did not have many friends, the review states.
Jonathan started to use cannabis when he went to college at 16 and his mother thought that most of his friends were associated with his cannabis use. His behaviour became more erratic from the age of 19, including: talking about aliens, believing everyone was trying to kill him and isolating himself.
A medical review was completed in February 2019 in which Jonathan demonstrated that he had little understanding of his psychotic illness.
During interviews with the Cygnet staff, staff members were able to describe changes made since Jonathan’s discharge to mitigate against the issues identified from occurring again.
For example, the record-keeping on the ward has changed: a patient’s Section papers are subject to scrutiny a minimum of three times and are signed off by the MHA lead, the Operations Manager and the Hospital Manager.
Concluding the report, the joint review found that Jonathan’s ‘inadequate discharge’ from Cygnet Health Care can be identified as the ‘significant service delivery issue that contributed to the homicide.’
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