The Mental Welfare Commission for Scotland found the specialist team that cared for Mr F, who killed his father at the home they shared in the summer of 2007, had a “strong regard” for him, but failed to “recognise the true extent of his psychosis or the level of risk arising from his past behaviour, his history of alcohol misuse and the particular psychotic symptoms that he experienced”.
Mr F, 41, had suffered from alcohol problems since his teens and received care from a dual diagnosis team that provides treatment for people who have a mental illness and issues with substance misuse.
The commission said he suffered “paranoid delusional beliefs” and although he received “good care” for his alcohol problems, his mental illness was “undertreated”.
He heard voices telling him that his father, who had verbally and physically abused him since he was a child, intended to harm him but the care team believed he was capable of resisting acting on his thoughts.
The commission said Mr F’s mother, who was estranged from his father, had contacted services to voice her concern about his threats to kill his father. A risk assessment was due to take place in January 2007 but there was no evidence that it was held.
The report said: “It is our view that the dual diagnosis team who were most closely involved in managing Mr F’s care and treatment became too close to him to be objective. They could no longer distance their good relationship with him from the assessment and management of the risks he presented.”
Mr F had been in contact with social work services for 11 years before the attack, but the commission found there was no evidence that a full assessment of his needs had ever been undertaken.
Mr F regularly cared for his two children and “despite clear potential risks”, the commission found that information was not shared between health and social work departments. Linda Graham, HM Commissioner for the Mental Welfare Commission in Scotland and chair of the investigation team, said: “A whole family have suffered a huge personal tragedy in this case. Homicide committed by people with mental health problems is still extremely rare.
“There is a bigger population of people with schizophrenia and alcohol addiction problems currently receiving care in Scotland. We hope that this case will mean that lessons can be learnt.
“We would ask health and social care providers and the Scottish Government to review the recommendations in this report to establish what actions they need to take to help avoid similar incidents in future.”
A Scottish Government spokesman said: “We agree with the Commission that it is critical to consider not only the risks posed by restricted patients, but also by any patient who may pose a threat to other people.
“We issued guidance making this explicitly clear to health boards more than two years ago – and tightened it last year when we instructed boards to make a named senior manager responsible for monitoring this guidance in practice. We will work closely with the Commission to consider what further action may be required.”
