The Welsh Assembly Government’s response to the Paul Khan Homicide Review

On 1 December 2004, Cardiff Local Health Board published the report of the independent external review into the care management arrangements and events leading up to the homicide committed by Mr Paul Khan. In March 2003, Mr Brian Dodd, a retired accountant, was stabbed to death by Paul Khan while out walking his dog on Ffrith beach in Prestatyn. Paul Khan suffers from paranoid schizophrenia. At the time, he was cared for under licence by community mental health services in Cardiff, following a conditional discharge from medium-secure accommodation at the Caswell clinic in Bridgend. This followed a previous offence in 1996. Cardiff Local Health Board was asked to commission an independent external review into this case by the Assembly Government in October 2003. The overall aim of the review was to ensure that lessons could be learned from this terrible tragedy, so that all could be done to reduce the risk of such an event happening again.

The review’s report has now been given careful consideration. This has included an independent assessment by the chief executive of Healthcare Inspectorate Wales. The report has highlighted a number of key failures in Paul Khan’s care. It has provided a comprehensive assessment of where there were clear weaknesses in the system and processes in place. In doing so, it has provided a vehicle upon which to identify the lessons that need to be learned. I am also assured by HIW that the process of investigation used in this case—root cause analysis—was appropriate.

The Assembly Government will therefore accept the report’s findings and is committed to ensuring that its recommendations are taken forward. The report has highlighted a number of key areas where further work is now needed within mental health services in Wales to assure users, carers and the public that systems and practices are robust. In addressing the range of recommendations in the report, work will be taken forward across four key areas: discharge planning, care planning and review, contingency planning, including risk assessment, and ensuring compliance with legal and statutory reporting requirements. This comprehensive approach will ensure that we see improvement in the quality and safety of care provided across the care pathway for patients such as Paul Khan. I have therefore determined that there is little to be gained from any further review of this individual case, and have ruled out the need for a statutory inquiry. However, this is not the end of the matter.

The emphasis now needs to be placed on moving forward—seeking improvement, rather than looking back. There are many lessons to be learned from this tragedy, and this is what we need to do. I reassure you that work is already under way. Health Commission Wales has commissioned a review and audit of discharge planning arrangements from all medium-secure mental health units in Wales. This is being complemented by a clinical governance inspection by Healthcare Inspectorate Wales, which is due to report in May this year.

The findings from this work will be used to determine what further guidance is needed, or where there may simply be a need to reinforce existing guidance. It is then planned to issue advice to local health boards, trusts and social care services later this year. In the meantime, I expect all organisations to review the report’s findings and recommendations to satisfy themselves that the services that they commission or provide are satisfactory. I am pleased that all stakeholders involved in Paul Khan’s care have so readily accepted the report and are taking action to ensure that the failures identified in Paul Khan’s case will not happen again. It is important that any of this learning is shared across Wales.

This has been a tragic event, and our thoughts are, again, with those touched by it. I assure them and the public that the Assembly Government is committed to taking action to ensure that lessons are learned from this tragedy.