BackA knife attack might have been prevented if the perpetrator had received better mental health care, an investigation by England’s Health Ombudsman has found.
In November 2020, a 31-year-old man stabbed a man in his thirties, just one month after being discharged from the care of Kent and Medway NHS and Social Care Partnership Trust, now called Kent and Medway Mental Health NHS Trust. He was arrested and later detained under the Mental Health Act. After the attack he was diagnosed with schizophrenia.
The Parliamentary and Health Service Ombudsman (PHSO) found a series of failings by the Trust in the 12 months leading up to the stabbing. These included poor care planning and discharging the patient without reviewing his risk level.
The Ombudsman concluded that these failings might have contributed to the man’s mental health decline. Had he received safe and appropriate care, the stabbing might not have occurred.
PHSO has repeatedly raised concerns about systemic failings in mental health services. In 2024, the Ombudsman published a report highlighting failures in transferring people with mental health conditions out of services. The report found failures in planning, communication, and continuity of care, and called for services to be more holistic, joined up, and person-centred.
Rebecca Hilsenrath, Chief Executive Officer of PHSO, said, “This is a sad case involving a vulnerable man who posed a risk not only to himself, but to others. A risk that tragically became reality when he attacked an innocent member of the public. It highlights the stark consequences of poor mental health care, not just for patients, but also for their families, carers and even strangers.
“The patient’s mother repeatedly raised concerns about her son’s deteriorating condition and the risks he posed. She was so fearful that she felt forced to hide in her car rather than remain in the home they shared. Despite her repeated pleas for help, she was badly let down by the Trust and left to cope alone without the support she urgently needed.
“For over a year, she endured a frightening and distressing situation. During periods when her son was in crisis, her requests for help went largely unanswered, leaving her in fear for her safety. Good mental health care must include truly listening to families and using their unique insight to inform care decisions.
“There is still significant work to be done to embed a culture within mental health services that learns from past mistakes. While there have been some improvements, including steps towards reform of the Mental Health Act and ongoing Government inquiries, these must lead to real change on the ground – change that improves services and keeps people safe.”
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Source: The Parliamentary and Health Service Ombudsman (PHSO), UK
