"Missed opportunities" in cases of men who went on to murder in Bristol and Weston
Mental health services missed opportunities to act in the care of men who went on to kill, two independent investigations have found.
But it is not believed that interventions from Avon and Wiltshire Mental Health Partnership (AWP) could have prevented the deaths of Terrance Hall and Alan Riddock.
The deaths, which both date back to May 2008, were the subject of independent investigations into the treatment provided by the mental health partnership commissioned by NHS South West, which have been published today.
They found weaknesses in some of AWP's care of James Allen and Liam Churchley, but did not believe they had a direct effect on the killings.
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Allen was convicted of murdering his neighbour Terrance Hall in July 2009. He hit Mr Hall with a baseball bat outside his flat in Walliscote Grove Road, Weston-super-Mare on May 7.
Alan Riddock was killed outside the Park House pub in St John's Lane Bedminster on May 24. Diane Churchley, her son John and his cousins Jason and Craig Hartrey were all convicted of the murder of Mr Riddock in April 2009. Another son, Liam Churchley - who had been involved with mental health services since 2002 when he was 14, was convicted of manslaughter.
Allen, referred to in the report as Mr Y, had a history of drug misuse and had initially been referred to the North Somerset Specialist Drug and Alcohol Service in October 2001 – which was then run by AWP - but it was not until late 2005, having also used services in Bristol, Allen reported that he was no longer using drugs.
He had reported psychotic-like symptoms, the report said including auditory hallucinations and described feelings of being "paranoid and suspicious" and had taken anti-psychotic drugs for several months in 2005.
He was diagnosed as having an "emotionally unstable personality", which the report said did not appear to have been explored.
Allen was involved in three assaults and a number of fights while under the care of the drug and alcohol service and charged on at least two occasions, the report said.
"With the benefit of hindsight these must be regarded as near misses", it said, adding that while the drug and alcohol service might not have been primarily responsible for the risks, it would have been good practice to work with the probation service to see how the problem could be assessed.
A prison psychiatrist who assessed Allen when he was detained in prison found no evidence that he was suffering from a serious mental illness.
The report found that delays in assessing Allen and engaging him in services "did not reflect best practice and resulted in his needs not being addressed in the most effective manner".
It found that he was not assessed in a comprehensive manner and assessments were not planned as they should have been. Care plans did not provide clear information about his behaviour or identify any risks.
It said: "Various risks behaviours were identified in Mr Y's clinical notes but these were not brought together in a single, easily identifiable place."
They said Allen's care and treatment could have been more coherent if this information if this information had been recorded appropriately.
"However it would not be reasonable to conclude that this had a direct effect on the events of May 2008", the report said.
It also found that psychological interventions were not offered to Allen, which was "a weakness in the care offered to him".
The report into Churchley, who was referred to as Mr Z, said that he had been supported by the child and adolescent mental health service and had been admitted to hospital under the mental health act in 2002.
The report said he had a history of self-harm but by the end of April 2007 his contact with mental health services was "increasingly sporadic" as he missed a number of appointments and assessments by the community psychiatric team tended to come after he had been detained by the police.
He had experienced episodes of psychosis related to a "troubled upbringing" and drug use.
Churchley was arrested the day before Mr Riddock's death in connection with two burglaries. He was assessed and said he was depressed and hearing voices. His mother said he was unwell and should be in hospital.
The report suggests that mental health professionals could have been "more assertive" in their approach with Churchley and concerns about his siblings.
It described the failure to hold a care planning meeting with Churchley and his mother as a "missed opportunity to establish a strategy to address Mr Z's needs in the most effective manner".
But they said it would not be reasonable to conclude that failings in risk assessment and action had a "direct causal relationship with the events of May 24, 2008", although the reports said there were lessons that could be learned.
Recommendations in both reports focused on how joined-up working could be improved in the future, reviewing when patients were followed up by mental health services and ensuring care plans reflected the needs of the individuals.
AWP accepted the findings of the reports, which they had investigated in 2008.
Medical director Arden Tomison said: "The investigation reports acknowledge the considerable efforts made by our staff to support each service user in the years leading up to the incidents.
"Across the trust our staff deal with individuals whose complex needs, behaviour and reluctance to be helped can make delivering effective care and support very difficult. The decisions our staff make about the care and support provided to service users are informed by the best clinical understanding of their individual needs."
Deborah Hall, Terrance's partner, said: "Terry died unnecessarily.
"Terry does matter and we have waited nearly five years for some answers.
"This whole process has had a big impact on the family and we feel it is too easy for the victims to be forgotten.
"We hope that this report goes some way to protecting innocent people in the future."