Scandal of patient blunder

A health worker did not know for more than a year she was supposed to be responsible for a mentally ill patient who became a crazed killer and drowned a Black Country pensioner, a damning report has revealed.

Widow Irene Norman, aged 84, was kicked and dragged into her bath by her neighbour Donald Benion in Stowlawn, Bilston, on November 27, 2002.

Benion will remain in a secure mental hospital for the rest of his life after pleading guilty to manslaughter on grounds of diminished responsibility in February 2004.

An inquiry, which took 16 months of complaints by the victim's family to be commissioned, revealed he received inadequate mental health care from Wolverhampton City Primary Care Trust (PCT).

It highlighted "a range of concerns that collectively allowed" Benion to fall out of contact with mental health services, the West Midlands NHS board heard yesterday.

In September 2001 Benion's care co-ordinator left the trust and his case was allocated to another care worker, but she did not become aware of this responsibility until October 2002 - a month before he killed Mrs Norman.

The investigation referred to Benion as W1. Among the failures highlighed were:

l The hand-over of care co-ordination responsibility in September 2001 was ineffective.

l The requested and required review of how his care programme was dealt with did not happen.

The report said: "Whilst there are no guarantees contact with W1 would have revealed any behaviour suggestive of an increase in his risk factors, the fact that he was not seen leaves this open to question."

By Health Correspondent Andy Rea