Nurse’s career ‘blighted because he opposed release of patient who went on to be a killer’

Martin Shipton

A former head of nursing at an NHS clinic in Wales says his professional career was blighted after resisting the initial release from a secure hospital of a schizophrenic who subsequently randomly killed a pensioner on a beach.

Instead of being thanked for flagging his concerns, Barry Topping-Morris says he was branded a troublemaker and removed from his post at the Caswell Clinic in Bridgend.

Almost two decades later, he is still seeking justice and believes lessons remain to be learned for the safety of the public.

Mark Drakeford

In pursuing his campaign he has the support of First Minister Mark Drakeford, his constituency MS, and other current and former Members of the Senedd.

Paul Khan had been sentenced to an indefinite hospital order in 1996 after a knife attack on a man in a Cardiff library. He was detained at Ashworth Maximum Security Hospital in Liverpool.

After this first attack Khan pursued legal action against Whitchurch Hospital in Cardiff, alleging that his condition had not been properly diagnosed and treated. The hospital did not admit liability but Khan received compensation in an out-of-court settlement.

Two years after being sentenced for the Cardiff attack, despite documented concerns from Mr Topping-Morris that were ignored, Khan was transferred to the NHS’s medium secure Caswell Clinic.

In 2000 a mental health tribunal ruled that Khan could be treated in the community and he lived independently.

In March 2003, Khan, who had stopped taking his medication, drove to Prestatyn with his dog. He arrived at the town’s Ffrith Beach and attacked retired accountant Brian Dodd, 72, who was walking his two dogs, with a large kitchen knife.

Mr Dodd died after suffering at least 28 knife blows to the head, neck and chest. Days later, Khan was arrested in an altercation in Newport. He was jailed for life at Chester Crown Court in October 2003.

Mr Topping-Morris refused to go along with what he, and others, feared to be a cover-up within the NHS. He says false allegations were made against him that resulted in his being removed from his post. When the allegations were disproved, he wasn’t reinstated.

Instead, he has had to work in other roles at distant locations that have disrupted his family life and set back his career.

Risk assessment tool

Previously Mr Topping- Morris had developed an evidence-based pre-admission nursing risk assessment tool that proved to be as predictive of risk and danger as any other known psychiatric risk assessment tool. The risk assessment was first used in 1992 and between then and 2005 had been successfully applied as a reliable predictive tool. Ironically, during all this time, the only patient initially deemed to have been too dangerous to admit to the Caswell Clinic was Paul Khan. It is understood that this patient was the only one to subsequently go on to commit a homicide. The clinical significance of these facts has yet to be examined by any agency.

Mr Topping-Morris has tried without success to get an apology for the blighting of his career and says his story shows how there should be a fundamental change in the way homicide cases are investigated where people with mental health problems are the perpetrators.

Mr Topping-Morris said: ”There has been significant media attention given to homicides committed by persons with mental health problems. I believe we need a major change in homicide investigative processes involving the NHS so they become fully external and independent, involve lay persons and are trusted – the aim being to ensure secure healthcare in the interests of public safety. We are currently failing to learn lessons because the unwritten government and NHS objective is that no blame should be attached to forensic psychiatrists.”

Public safety

Mr Topping-Morris said he wanted to make it clear that all of his comments to Nation.Cymru were designed to improve patient and public safety and that they could be evidenced. To date, however, NHS Wales had done everything it could to avoid doing so. He said: “I also want to make it clear that I carry an accountability to alert persons in authority to any threat to public safety, but the responsibility for fixing it is not mine but lies with NHS Wales and Welsh Government. The stakes are high: the victim’s family, long ago, were the first to make claims of a cover up and the perpetrator and his family have previously successfully gained from claiming that his diagnosis and treatment needs were neglected.

“If a cover up has occurred and the perpetrator’s treatment needs were neglected once more then it would be extremely challenging to put this right.

“For my part, nothing could put right the pain and suffering my family and I have experienced due to this injustice. My conscience is clear – I did the right thing in raising concerns, it was my duty to do so, and despite my maltreatment I remain proud of my many career achievements.

“My claims are simple: I informed the executive officer that we had not conducted an internal clinical review (he agreed and asked me to remedy this) and I then found a dishonest letter to the Home Secretary and reported this to persons in authority. My first claim can be verified by existing records and my second claim, although the letter itself has gone missing, is corroborated by the existence of a similarly dishonest letter to Paul Khan’s solicitor and supported by exchanges made directly to me in a 2018 email from a senior official at the Ministry of Justice.

“The Welsh Government claims there is no evidence to support my claim that documents were removed from the clinical file, yet their timeline notes that the ECRI Homicide Inquiry report did make reference to missing documentation in Whitchurch. So, if documents were missing from the Whitchurch files, why couldn’t they have been missing from the Caswell files?

“The only truly independent examination of events concerning the homicide was conducted by ECRI Homicide Review, named after the healthcare safety body of that name, but it was not furnished with all available evidence. If ECRI had been given access to withheld documents then I am sure they would have drawn far more damning conclusions.”

Senedd

In 2019, the then South Wales Central Conservative MS David Melding raised Mr Topping-Morris’s concerns at the Senedd, asking: “I would like to request a statement from the Minister for Health and Social Services on the case of my constituent, Mr Barry Topping-Morris. Mr Topping-Morris was the head of nursing at the Caswell Clinic in the then Bro Morgannwg NHS Trust when he was removed from post in 2005.

“He had brought to the attention of senior management what he considered irregularities in the assessment and treatment of a patient. These concerns emerged when Mr Topping-Morris conducted an internal review into a serious case and in preparation for a visit by Health Inspectorate Wales. I am concerned that Mr Topping-Morris’ subsequent treatment as an employee might have been adversely affected by the way he sought to exercise his professional judgment in applying constructive challenge in this difficult case.

“A number of reviews have been held, but none on the employment practices. The most recent review carried out on behalf of the Abertawe Bro Morgannwg University Health Board In March 2015 stated that the employment concerns ‘were not within scope of the review’. It appears that Mr Topping-Morris’ employment concerns have never been properly investigated, and given that these may be relevant to wider issues of public interest, I would urge the Minister to commission a further review, so that closure can at last be made to this case.”

No such review of the employment matters has taken place,

Internal review

Mr Topping-Morris said: “Central to my case is how and why I was prevented from sharing my concerns with independent bodies and how, despite my being asked to complete an internal review, my concerns were not passed on to Health Inspectorate Wales (HIW) and Health Care Wales (HCW) during my enforced absence.

“In 2014 Abertawe Bro Morgannwg University Health Board (ABMUHB) accepted responsibility for reviewing my case. They appointed Mandy Collins to complete the review. Mandy Collins was actually the chair of the original HIW team tasked on December 1 2004 by Ann Lloyd, the then Chief Executive of NHS Wales, to examine discharge arrangements in the Caswell Clinic after the ECRI Homicide report was published.

“The Mandy Collins review report was shared with me in 2015. In the report there is very clear evidence of many documents that are not referenced in either the ECRI report or the subsequent HIW/HCW reports. Both ABMUHB and its successor organisation Swansea Bay UHB have each, in turn, deflected any responsibility for examining the significance of these documents in learning lessons from the homicide. Equally, neither will accept responsibility for examining the significance of the dishonest letter sent to Paul Khan’s solicitor. Crucially, Ms Collins identified the existence of a letter sent to Paul Khan’s solicitor on November 4 1997 from the Clinical Director of Mental Health indicating the nursing assessment had been completed. In fact, it had not been.

“When Ms Collins met me to explain the conclusions of her report she confirmed that she found evidence that supported my claim that the executive officer had asked me to undertake an internal clinical review before the arrival of the joint review team. Crucially, Ms Collins informed me that had she been made aware of my concerns as she undertook her review in 2005 she would have given far more scrutiny to the 2005 review. I firmly believe that Ms Collins, like me, has been deliberately disempowered from revealing the truth. Who decided what information was to be shared with ECRI and other investigative bodies?

“The Mandy Collins report reveals the answer to this question but to date no organisation has been given the opportunity, or is willing, to examine this evidence. ABMUHB and its successor organisation SBUHB have repeatedly claimed that they would consider new evidence but are being unreasonably selective on what constitutes new evidence. The new evidence revealed, perhaps unwittingly, by Ms Collins has never been examined nor has my personal experience of employer bullying and harassment between December 1 2004 and January 13 2005. It was only when I received the Mandy Collins report in 2015 that the significance of earlier events began to unfold.

“I was removed from my post without good cause before the arrival of the joint HIW/HCW review team. Although executive and senior managers were aware of my concerns they did not relay such information to the visiting review team.The failure to conduct an internal investigation or to reveal the anomalies and omissions to HIW/HCW represent serious clinical governance concerns. If any of these failures were intentional then it would clearly amount to criminal acts of misfeasance in a public office.

“I was kept at arms length from the ECRI Homicide Inquiry and then deliberately prevented from giving evidence to the HIW/HCW review. These are serious governance issues and public safety has been compromised.

“In my view I was clearly targeted by my managers after I raised concerns about their governance approach to learning from a tragic homicide. The refusal to address my concerns had then, and still has now, serious implications for public safety. I believe that senior executives and managers were heavily invested in the protection of its specialist service and of the trust’s reputation and I became their scapegoat by default.

“Further, their failure to investigate the full extent of the anonymous letter that resulted in my removal from my post and their refusal to confront the wrongdoing I have identified, together with their refusal to involve the police at my request, have each infringed my employment and human rights. And if all that is not enough, they failed in their duty of care owed to me when they did not support me beyond my forced departure.

“Despite making many representations to my former employer, successor organisations, public bodies including the Ministry of Justice in Westminster and the Welsh Government, events that unfolded following publication of the ECRI Homicide review on December 1 2004 and my removal from post on January 13 2005 have yet to be independently and carefully examined. Those 44 days blighted my career and family life irreparably.

“To date, there appears to have been a concerted effort by NHS Wales to avoid looking at this critical timeframe. It was also a time when I suffered considerable bullying and harassment both in my workplace and even in my own home – and this was compounded by damning news reports fuelled by concern from the widow of the victim.”

False allegations

Mr Topping-Morris said the false allegations were made against him at a critical moment when significant omissions were at risk of being discovered. As a result he was swiftly removed from his post. He said: “I repeatedly shared my concerns with my employer and successor organisations, but to date they have fallen on deaf ears. They did then, and still now, refuse to accept responsibility for learning lessons.

“No agency has yet examined the quality of multi-disciplinary decision-making in the care and management of Paul Khan. He is also a victim of this tragic homicide, for he too could and should have received effective care and treatment. The original reviews – ECRI and HIW/HCW – never could examine this crucial dynamic because the key documents identified in the Mandy Collins report were withheld.

“I didn’t realise that by speaking out it would cause such distress and detriment to my life, my family and my career. This is still ongoing and closure for me is as far away as ever.

“After 33 years in the NHS with 18 years of service to my employer in Wales, without ever having faced disciplinary action, and despite the investigation that followed the malicious anonymous letter concluding that nothing had emerged to suggest a need for disciplinary action, I was informed I could not return to my post. My nursing career in Wales was prematurely and brutally ended. This was compounded by a series of adverse and anonymous press leaks and my sudden forced departure from my prominent position created a ‘grapevine’ across the senior echelons of the Welsh NHS.

“This is the central nub of the injustice I have suffered and it has resulted in a significant loss of earnings, stunted career opportunities and many other lifetime losses.

“The Welsh Government in its timeline relating to my case cites a number of reviews into my concerns: desktop reviews, meetings, the 2015 Mandy Collins review and more recently the 2021 review, but none of these were undertaken by anyone with experience or understanding of the management of mentally disordered offender patients, their risk management and its role in protecting public safety.

“The Welsh Government review was undertaken in early 2021 yet the ‘notes’ were only shared with me in May 2022. The notes reveal many inaccuracies and confirm that the review was adjourned, never to reconvene. This is not good governance on the part of the Welsh Government. The ECRI review did have this expertise but it remains to be seen if they were in fact given access to all of the information that they requested.

“The Welsh Government has claimed that at its most recent review of my case in March 2021 I had the opportunity to speak directly with the independent reviewer and did not provide any additional evidence for consideration. Yet the meeting was adjourned while its reviewers, none of whom had any experience or understanding of the management of mentally disordered offenders, declared they needed to take advice on the next steps. I expected that the meeting would be reconvened to hear my evidence of my experiences between early December 2004 and January 13 2005. But no consideration of this crucial timeframe has happened to date.

“The Welsh Government claims that ‘None of the investigations undertaken to date have provided any evidence that his concerns are founded’. Yet the content of the review undertaken by ABMUHB, cited in the government’s own timeline, and shared with me on March 4 2015, very clearly contains evidence of numerous documents that do not feature in the ECRI Homicide Review Report nor in the joint HIW/HCW Review. Of relevance is clear evidence that letters were written to both the Home Office and the relevant legal representative on the same date on other occasions.

“The Welsh Government’s review conducted by teleconference during lockdown Covid restrictions in March 2021 asserts that my claim that a dishonest letter sent to the Home Office is unfounded and that the MoJ claims ‘there was no sign of further correspondence’ and that the MoJ did not identify any additional correspondence that has not already been reviewed as part of the investigation.

“However, ironically, the Welsh Government does concede that a senior official wrote to Paul Khan’s solicitor in a private capacity stating that the nursing assessment had been completed. It had not been. “It must be stated that Paul Khan was and remains a patient of NHS Wales. The Welsh Government seems happy that a patient of NHS Wales can be misrepresented in such a remarkable way. Would any independent person share this view? Would Paul Khan’s legal representative share this view? Is Paul Khan’s legal representative entitled to know that they were misled? What might have happened to the care and treatment of Paul Khan if this misrepresentation had not occurred and instead a truly multi-disciplinary approach had been embraced from the point of pre-admission assessment and beyond? What would ECRI think of this misrepresentation? Who decided which documents would be given to ECRI?

“My Senedd Members continue to support me in efforts to achieve justice and closure. My aim was always about improving and advocating and making sure that the public and my patients were safe.

“I am very clear that the care and treatment of mentally disordered offenders is a very difficult challenge. If not planned carefully, with full multi-professional support, then successful outcomes are not possible.

“This case was destined to fail from the start because best practice was not followed. This was a tragedy that could and should have been averted. If all of the facts were independently examined, I am confident my concerns would be confirmed.

“I cannot overlook how my concerns have been met by NHS Wales and the Welsh Government. At every juncture it’s been more of the same: denial, deflection and obfuscation repeated frequently and designed to make me give up or go away. This shows indifference to the experiences of the perpetrator’s and victim’s families.They are interested only in protecting corporate and political interests.”

Wrongs

First Minister Mark Drakeford, speaking as the constituency MS who took up the case, said: “I have known Barry Topping-Morris throughout the time that I have been Senedd Member for Cardiff West. He has worked tirelessly to draw attention to the wrongs which he believes to have been committed 20 years ago. In my experience, Barry has always been focused on his wish to see the system improved for the benefits of others.”

Former MS David Melding said: “Of all my casework during 22 years in the Senedd, Barry’s case remains among the most troubling and sadly unresolved. NHS staff must be confident that they can exercise their professional judgement and raise concerns regarding patient welfare and public safety. Employment and HR procedures must achieve best practice for clinical governance to reach the highest standards. In my many discussions with Barry he has emphasised the need for teamwork and multi-disciplinary decision making to be at the heart of the NHS. This case is not only about how Barry was treated as a senior NHS clinician. It is also about how we learn lessons to make the NHS even safer and more effective, and this is especially important in the most challenging areas of healthcare.”

A Welsh Government spokesperson said: “We cannot comment on individual cases but work is underway to change how homicide reviews are undertaken and to ensure there is a consistent cultural expectation, approach and escalation process when staff raise concerns.

“We are introducing the Single Unified Safeguarding Review (SUSR), undertaken by multi-agency Regional Safeguarding Boards, to create a single review process which will include mental health homicide reviews. This new approach eliminates the need for families to take part in multiple, often onerous and traumatising reviews and will more quickly identify learning; build a greater understanding of what happened during an incident and why, and provide a clear action plan to improve services. Importantly, it will ensure learning is adopted throughout Wales.

“The Speaking up Safely Framework for NHS Wales, will strengthen procedures and provide assurances to NHS staff that concerns will be taken seriously, heard fairly and that speaking up will not result in them facing issues in the future.”

Swansea Bay UHB

A spokesperson for Swansea Bay UHB said: “The events described date back more than 20 years. They involve a predecessor organisation and a patient who is still under the care of the NHS. For those reasons it would be inappropriate to comment.”

Responding to the Welsh Government’s statement, Mr Topping-Morris said: “They are only now taking infant steps towards accepting their duty of candour and a need for transparency.

“They have a long way to go. In my case, where an innocent man lost his life in a tragic and violent way and other victims have had to endure life-changing circumstances, it is simply inexcusable. I am hoping that a cultural shift will occur as we learn lessons from more recent events.”