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Care blunders 'failed to stop' knifeman who went on stabbing spree
Robert Mendick9 Mar 2009
An inquiry into the care of a psychiatric patient who stabbed one man to death and maimed five other victims today condemned blunders in his treatment.
The independent report blames 23 "critical" failings by staff caring for paranoid schizophrenic Ismail Dogan, who killed Ernest Meads, 58, during his deadly stabbing spree across north London.
The 175-page investigation into Barnet, Enfield and Haringey Mental Health NHS Trust and NHS Haringey also reveals a cover-up by one of Dogan's key carers.
The unnamed nurse altered the patient's medical records in a bid to make it appear that Dogan, 32, from Tottenham, was properly assessed. She has now been suspended but investigators are demanding a probe into records she kept on dozens of other patients.
Today the families of Dogan's victims criticised the four-year wait for the publication of the report. Health bosses blame the delay on administrative changes to the NHS in London.
Mr Meads's sister Pamela Stuart said: "I blame the system. Nothing seems to work. People are not in contact. The doctors and nurses didn't have things on record.
"The report doesn't name the doctors. It's like they are part of the system and you can't pick one out. The whole system has failed."
Turkish-born Dogan is now a patient at Broadmoor psychiatric hospital after he was found guilty of the manslaughter of Mr Meads who he killed with a six-inch boning knife in December 2004.
He also seriously injured Roger Levy, 51, Victoria Cann, 32, David Symes, 31, Raymond Day, 78, and Jeffrey Arthur, 52, during the hour-long orgy of violence between 8am and 9am around Tottenham, Wood Green and Edmonton.
The inquiry, commissioned by NHS London, reveals staff had numerous opportunities to prevent the breakdown in Dogan's mental health, which led to the stabbings.
It has emerged he stopped taking his anti-psychotic medication months before the attacks.
His medical notes identified him as a risk and showed that he had said he could hear God telling him to stab people.
Staff failed to act upon behaviour identified in the notes and ignored his parents' pleas for help on at least five occasions.
There were also communication failures between the police and health trust.
This meant that key information relating to Dogan's convictions for criminal damage and actual bodily harm was not picked up on.
Barnet, Enfield and Haringey Mental Health NHS Trust and NHS Haringey apologised to relatives for "significant shortcomings" in their services.
They said in a statement: "We again extend our sympathies to the victims, their families and friends, at what must once more be a difficult period for them.
"We are sorry that in the period leading up to these tragic events several years ago there were significant shortcomings in our service."
Reader views (4)
The first blunder was the worst: he was allowed to roam free.
time and time again we hear "he was fine as long as he was on his medication, but he stopped taking it"
This is no different, and another preventable death in the name of political correctness
- Trunk, US, 09/03/2009 16:16
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My mother suffers from paranoid schizophrenia and I could write a several hundred page book on the failings in her care over the last 30 years - some of which have put her personal health and safety and those of others at the highest possible risk and she has been assaulted abused in every way possible whilst supposedly detained under section. I would point out that where someone is psychotic and delusional it is mainly their own safety and life at risk, however if they do kill others that is even worse. All instances of murder committed by a person not responsible for their own actions are a tragedy for both parties and their families. If the NHS has that person securely Sectioned they should be held culpable both for murder and suicide.
The NHS repeatedly and sustainedly refutes failures of care even when there is clear proof. Having personally battled this, I can assure readers there is NO justice - not least of which is because they automatically bypass all accusations by stating a) the person involved is not of sound mind and b) that they cannot discuss that patient with other people and c) the family are 'interfering' and controlling and wish to dispose of their mentally ill relative in any way possible. The psychotic and delusional patient is oblivious to their actions and is the last person who will complain or comply with the wishes of bringing about complaints and even if they do, guess what, they're MAD so it doesn't count.
- Real, London, 09/03/2009 14:17
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There are many (probably hundreds of) cases of individuals with mental health issues not receiving the treatment and care they need and being sent out into the community with no one to ensure they are supported and taking their medication - the mental health care buget has been decimated over the years and the statutory sector relies heavily on the voluntary sector to provide the support and help for individuals suffering from mental ill health. Without voluntary organisations like MIND and SANE where would the 1 in 4 affected by mental health issues turn?
- Th, london england, 09/03/2009 13:33
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Was deportation an option?
- Ab, London, 09/03/2009 12:17
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