NHS failures led to Birmingham policeman’s murder

Sep 11 2009 by Christina Savvas, Birmingham Post

A catalogue of NHS system failures contributed to the killing of a police officer by a paranoid schizophrenic, an independent report has found.

Glaister Earle Butler stabbed detective constable Michael Swindells in the heart on May 21, 2004 after a chase along a canal towpath in Birmingham. The 44-year-old father was attacked as he went to help passers-by, being threatened by Butler who was armed with a kitchen knife.

The independent report revealed Butler, 50 at the time of the incident, was ‘let down’ by NHS outreach workers who failed to assess the extent of the risk he posed.

The inquiry – carried out for NHS West Midlands, the body which oversees health services – blamed system failures instead of individuals for the mistakes. Health chiefs said no one had or would face disciplinary action.

At the time of the stabbing Mr Butler was a patient under the Small Heath Assertive Outreach Team – run by the Birmingham and Solihull Mental Health Trust – following his discharge from a psychiatric hospital in October 2001.

He was convicted of manslaughter on the grounds of diminished responsibility and detained indefinitely under the Mental Health Act at a secure hospital.

A 282-page report into his care found outreach workers did not realise the extent of his illness, failing to comprehend the risk he represented. The inquiry found the team responsible for monitoring him engaged in only ‘brief interaction and superficial contact’, often visiting him only every fortnight.

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.

> Police weren't told of danger posed by mentally ill patient