The NHS ‘missed opportunities’ to protect a mother and her baby son who were stabbed to death by her mentally ill ex-boyfriend, a report has said.
Rachael Slack, 38, and 23-month-old Auden were found dead at their home in Holbrook, Derbyshire, after being stabbed by Andrew Cairns, 44, who then killed himself, in 2010.
An independent investigation was commissioned by NHS England after it was revealed that Cairns was in contact with mental health services provided by Derbyshire Healthcare NHS Foundation Trust prior to the deaths.
Rachael Slack (left), 38, and 23-month-old Auden (right) were stabbed to death in Holbrook, Derbyshire, by Andrew Cairns, 44, who then killed himself in 2010
An independent investigation was commissioned by NHS England after it was revealed that Cairns (pictured left) was in contact with mental health services
According to the report, which was published today, a ‘systemic missed opportunity’ during his treatment was that Ms Slack and Cairns’s sister were not invited to provide ‘valuable information and insights into his mental state’. The authors said this could have helped with an ‘understanding of his personality and illness, as well as any potential safe-guarding issues’.
In addition, the investigation team found ‘information sharing between various medical services involved in his care was not as efficient as it could have been, resulting in delays in diagnosis and treatment’.
However, the investigation team praised the Trust for giving him ‘appropriate treatment’ for his depression, personality disorder and he received immediate crisis response when it was required, and ruled the deaths were not preventable.
In response to the report, Ifti Majid, acting chief executive at Derbyshire Healthcare NHS Foundation Trust, said: ‘I am sorry for these missed opportunities and I am sorry for the loss that resulted from this sequence of events.
‘We fully accept the recommendations made in the independent investigation report. A robust action plan has been developed in response to the recommendations made and we are committed to delivering these in full.
‘In 2010 the Trust undertook a thorough internal investigation into the care and treatment provided to [Cairns] prior to his death. This investigation identified a number of areas where the Trust could learn lessons, continually improve the quality and effectiveness of our services, and minimise the possibility of a reoccurrence of similar events.
‘A formal action plan was developed and I can confirm that all recommendations have been completed, in full. The improvements we have made in response to the learning identified by this tragic set of circumstances and subsequent incidents mean that the services provided by the Trust today are very different to those that were offered in 2010.’
Cairns was released on bail five days before the murders, after having twice been held by police.
The Independent Police Complaints Commission also launched an investigation in 2010 after it emerged Ms Slack reported him to officers when he threatened to kill her.
The murder-suicide occurred five days after Cairns was released on bail after making threats to kill Ms Slack
Its initial report that year found ‘no indications’ any officers had breached professional standards, before an inquest in 2013 found police failure ‘more than minimally’ contributed to the deaths.
A subsequent review later identified ‘human error’ after police failed to warn her that she and her son were considered at ‘high risk of homicide’.
Sandra Horley, chief executive of domestic violence charity Refuge, said: ‘The NHS is a vital gateway to support for abused women and children. Staff must be trained to identify domestic violence and protect victims.
‘By taking too narrow a view of [Cairns’] risk to himself, the NHS did not spot widely recognised domestic abuse risk factors that could have shone light on the danger to Rachael and Auden Slack such as: separation being the most dangerous time for abused women; pregnancy and childbirth being times of increased risk; babies being at highest risk of homicide; that three quarters of domestic homicides occur during separation; and that abusive men who threaten suicide often kill their partners and children first’.
‘We are dismayed to think of the stress Rachael must have experienced’, say her family
Pictured are Hayden and Melony Slack
Hayden, Rachael’s brother, and his wife Melony issued a statement today after the NHS report.
It states: ‘Our family welcomes this thorough and thoughtful report which identifies meaningful lessons.
‘We understand that the tragedy of 7 years ago could neither have been predicted nor prevented, based on what was known at the time. It is however clear that many chances were missed in sharing vital information which could have provided a clearer understanding of the situation.
‘We are particularly reassured by the recommendations made in this report to improve communication between all those involved in a patient’s care, to seek to involve the patients’ families in delivering appropriate treatment and to keep them better informed and supported after such awful events.
‘As parents ourselves, we are dismayed to think of the stress Rachael must have experienced; not only was she looking after a young baby – and latterly, pregnant again – but she faced the additional stress of caring for Andrew without effective support in challenging home circumstances. Recognition of the role of carer has developed nationally since Rachael and Auden were killed and we hope to see similar improvements and changes which also take into account the risks faced by women like Rachael associated with fatal domestic abuse.
‘The consequences of our tragic losses continue to impact upon our family, as they no doubt always will. It is our wish that the lessons are truly learned and the right actions are put in place to ensure sustainable change.’