Alex Robinson died at his home in Lincoln in December 2014 after his grandfather Stewart Greene, of Danes Court in Grimoldby, drowned him in the bath while the boy’s mum, Jo Greene, was out shopping.
Stewart Greene, who had been in and out of mental health units for many years before being discharged from in-patient care just a few days before the tragic incident, was later jailed for 22 years after he admitted murdering his grandson.
Once all related legal proceedings had concluded, NHS England commissioned an independent report, carried out by Niche Health and Social Care Consulting, in order to help the health service to understand whether lessons could be learned that could prevent a similar incident happening in the future.
The overall analysis listed at the end of the report focuses on the ‘predictability’ and ‘preventability’ of the potential consequences of how Greene’s mental health situation was dealt with.
The report’s analysis states: “There is evidence that (Greene) had been threatening towards his former wife and his daughter, however Trust records show that both (his ex-wife) Ms A and (his daughter) Ms J told staff that they did not believe he would harm his grandchildren.
“There is also evidence that (Greene) had been threatening towards staff and had actually assaulted staff in the weeks prior to being removed from the ward.
“However, we consider that it would not have been possible for Trust staff to have predicted that (Greene’s) behaviour would escalate to the degree that it would cause the death of
his grandson, Alex.”
The report continued: “We do, however, consider that there were actions that Trust staff could have taken that might have avoided (Greene) killing Alex.
“(Greene’s) discharge from the ward was rushed, there is no clearly documented rationale or discussion leading to the sudden decision to discharge him.
“The community mental health team had refused to allocate a care coordinator in accordance with the policy covering Care Programme Approach and staff felt that (Greene) was too high risk for staff to visit him at home.
“Whilst staff may have felt that (Greene) was unwilling to engage in support mechanisms that staff felt would benefit him whilst he was on the ward, he had clearly articulated his desire for intensive support when he was in the community.”
The full report, including the analysis of the case and the list of recommendations, can be found at www.england.nhs.uk/midlands/publications/independent-investigation-reports-for-midlands.
In a statement to the press following the publication of the report, an NHS England spokesman said: “The investigation team’s view is that it would not have been possible to
predict the incident.
“However, they did conclude that it might have been possible to avoid the incident happening if (Greene) had been discharged from in-patient care in a planned and structured way with an enhanced package of care.
“The investigation team has made 13 recommendations to the trust involved in (Greene’s) care, and two recommendations to local clinical commissioning groups.”
Speaking after the publication of the report this week, Nigel Sturrock, Medical Director for NHS England and NHS Improvement in the Midlands, said: “Today our thoughts and sympathies are with all those who have been affected by this tragic incident.
“Thankfully, events such as this are rare. When they do occur, we work closely with all organisations involved to ensure they are able implement the patient and public safety recommendations made by the independent investigation team.”