The way mentally ill patients are assessed and treated must be improved or more people will lose their lives, the brother of a man who killed his wife and ten-year-old son in a house fire said yesterday.
Don Philpotts spoke out after an independent report found the actions of his brother Harold, who had a history of mental illness and who also died as a result of the blaze, could not have been predicted.
Mr Philpotts is believed to have bludgeoned son Ben with a sledgehammer then started a fire at their Cornwall home. The ten-year-old and his estranged wife Patricia died.
Ben was pronounced dead at Royal Cornwall Hospital shortly after the fire took hold, while his mother died at the scene. Mr Philpotts, 47, died in hospital eight days after the blaze at the bungalow in Trevarrian, Newquay, Cornwall, on January 18, 2010.
An independent report into the mental health treatment Mr Philpotts received found there was no direct link between the tragedy and the care he had been given, although there were areas for improvement.
But his brother Don Philpotts said: "While the investigation concludes the deaths could not be predicted nor prevented, there is ample evidence to suggest otherwise."
He said best practice in dealing with families and carers was ignored – his brother's risk assessment should have been going "off the scale", but had not.
"More people will die unnecessarily," said Mr Philpotts, "unless rapid changes in practice are undertaken and the Department of Health ensures lines of accountability.
"Currently, Trusts can simply ignore best practice guidelines with no comeback."
The independent investigation – which refers to Mr Philpotts only as Mr A – was carried out by the Health and Social Care Advisory Service (HASCAS) and presented yesterday to NHS South of England's Patient and Care Standards Committee.
It said: "The Independent Investigation Panel concluded that the events of January 18, 2010, could not have been predicted nor avoided given the knowledge available to the Mental Health Services at the time.
"The provision of care and treatment to Mr A could have been improved but it did not of itself lead directly to the death of Mr and Mrs A and their son." At the time of his death Mr A was under the care of Cornwall Partnership NHS Trust, now Cornwall Partnership NHS Foundation Trust.
The independent investigation agreed with findings and recommendations from two internal investigations by the Trust, which showed Mr Philpotts had been diagnosed with mental health problems, probably schizophrenia and depression, but often refused to accept that he did and claimed instead to have physical issues.
The report said a more formal clinical history could have been obtained for Mr Philpotts, and mental health staff tended to take what he said at face value, without double-checking with his wife. He was not offered psychological therapies when he was first admitted to a mental health ward in 2008, and agencies did not share information enough, it found.
Mental health services and police worked in "relative isolation" from each other, it said, and did not share information which would have been helpful to both. A Serious Case Review previously highlighted the lack of contact between the agencies but also said the events of January 18, 2010 could not have been predicted.
The panel made six recommendations, including better risk assessments, especially where previous violence or use of alcohol or illicit substances is involved; prompt access to psychological therapy; better information sharing; and the need to challenge people who tried to not engage.
The panel found that Mr Philpotts' wife and family could have been asked about his history to prove or disprove what he was telling professionals.
It said treatment teams had an "over-optimistic view" of him as a "distressed, ill, but well-meaning man", and staff took what he said at face value. It also said his wife, who was under "almost constant pressure", was not offered a Carer's Assessment and could have benefited from a more proactive approach.
Dr Ellen Wilkinson, medical director at Cornwall Partnership NHS Foundation Trust, said: "Mr A found it difficult to accept his mental health, and as a result his engagement with services was neither consistent nor sustained. We have learnt from this incident and have made changes to the way care and treatment is delivered."
An electronic patient record had been introduced, allowing staff access to up-to-date information. Standardised risk assessment and management processes were now in place and information was now shared with children's services when one or both parents were receiving of mental health care and information was shared with police.
