Statement in response to publication of NHS England report into the care of Mr W

“I want to say sorry to the two families affected by the devastating incident in July 2015 which led to this independent investigation. Having met both families and heard about the pain they have been through, it is important to acknowledge that we got things wrong.

We fully accept all the findings and recommendations of today’s report. It highlights a range of issues that we are focused upon putting right in order to reduce the risk of something like this happening again.

We should have acted differently in relation to the care and treatment we provided to Matthew Daley and I apologise unreservedly for this. In particular, we were treating him for Autistic Spectrum Disorder but today’s report highlights that we had never undertaken a full, formal assessment to establish this diagnosis. We didn’t attach sufficient weight to his psychotic symptoms or his non-compliance with medication. We then failed to listen to the concerns of Matthew’s family and to undertake a clinical review of his care. As a consequence, we missed the opportunity to explore other treatment options such as therapy or hospital admission. 

In particular, the way we handled things at the time shone a light on the need for us to be much better at communicating with and supporting families. We have established family liaison roles, based on the model used by the police, to improve the way we do this.

When we make mistakes, we need to work together to understand what happened in order to reduce the risk of something similar occurring again. This can help us continue improving services for the patients, families and local communities we serve. That’s why, at the same time as saying sorry, I want staff to know I am committed to supporting them with the difficult, pressurised and complex job they do.

Today’s report is consistent with the learning identified by the independent, thematic review of homicides we commissioned in 2016 and published in the light of this tragic incident. We have a duty to the people who use our services, their families and the public to use this learning to help continue improving the services we provide.”

Sam Allen
Chief Executive

NHS England website

Action plan