Dc Michael Swindells’ killer was ‘let down by NHS’ – inquiry
Staff failed to spot that Butler had not been taking his medication. It was later found that medication was often posted through the letterbox – described as ‘questionable practice’ by the panel.
Workers were not unduly concerned when they spotted a kitchen knife on his sofa and stab marks on a door, accepting his explanation that he was practising martial arts, and failed to follow up.
Robert Francis QC, chairman of the investigation panel, said factors contributed to the killing included 432 doses of medication being found at his flat, the housing team was not aware of his treatment and outreach workers were unaware of his financial situation and of an eviction notice served on the day of the incident.
Mr Francis said the culture of the assertive outreach team was “reactive rather than being assertive which is what they are meant to be. They accepted what he was telling them... largely because he was considered to be low-risk. He should have been visited far more regularly and far more assertively. This was an assertive outreach team and yet many times they didn’t get through the front door, because they were afraid to put him off engaging.
“What was particularly striking in our investigation was the number of things that went wrong.”
When asked why it had taken more than four years since conviction to publish the review he said lessons should be learned to speed up such investigations but time was needed to interview the relevant people and collate years of health records.
The report and action plan will be presented at the NHS West Midlands’ board meeting today.
