A report into the tragic death of a nine-year-old boy at the hands of his grandfather nearly six years ago, says actions could have been taken to avoid the youngster being killed .
The NHS commissioned independent investigators to look into the case of Alex Robinson from Lincoln, who was drowned in the bath by his grandfather Stewart Greene in December 2014.
Greene, who was jailed the year after for a minumum of 22 years after admitting murder, had been in and out of psychiatric institutions from the 1980s.
He killed his grandson on December 23rd 2014. He was staying with his former wife after he had been suddenly discharged from a long stay in hospital.
The report states he should have returned to his home address some miles away but wanted to be with his former wife and near his daughter and her children.
When Greene's former wife and daughter went shopping with his grandaughter, Alex wanted to stay at home so was left in his grandad's care.
While they were out Greene locked the doors, ran a bath, walked Alex into the bathroom and drowned him. When the women returned from shopping Green told his daughter he had drowned Alex. She attemepted to resusciatate her son, but was unable to do so.
The report into the incident was commissioned by NHS England once all legal proceedings had finished. The investigation team has made 13 recommendations to the Lincolnshire Partnership NHS Foundation Trust, involved in Greene's care, and two recommendations to local clinical commissioning groups.
It concludes that while it would not have been possible to predict the incident, it might have been possible to avoid thei ncident happening if Greene had been discharged from in-patient care in a planned and structured way with an enhanced package of care.
The Lincolnshire Partnership NHS Foundation TrustTrust also commissioned a further specialist serious incident report that identified five concerns:
• Turnover of staff and lack of continuity of care on the ward.• Lack of a clear policy of how to manage the potential for criminal justiceproceedings if patients are violent.• Lack of contact with Mr Greene's family during his inpatient stay and at thedecision to discharge him.• Confusion about who was in charge of his care.• Lack of clarity about what might change a clinical decision if somethinghappens between the decision to discharge and discharge actually takingplace.
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