Crazed killers: Trust's failings exposed
Today, the Mail can reveal the damning findings of independent investigations into the cases of killers Benjamin Holiday and Michael Torrie, who were both patients of Humber Mental Health Teaching NHS Trust.
Holiday was receiving treatment for mental health problems when he stabbed 31-year-old Tina Stevenson, who was 31 weeks pregnant with twin boys.
He killed Miss Stevenson with a single stab wound to the back on January 5, 2005, as she walked down Wellsted Street, close to her Gee Street home in west Hull.
Holiday denied murder but admitted manslaughter on the grounds of diminished responsibility.
He was sectioned under the Mental Health Act and detained at Rampton secure unit, Nottinghamshire.
The independent report into his case – commissioned by the region's strategic health authority (SHA), NHS Yorkshire and the Humber, and carried out by Caring Solutions – states: "The root cause contributing to the patient's continuing severe mental disorder was that of 'under treatment'.
"His situation and condition could and should have been more assertively managed."
Michael Torrie killed his 82-year-old mother, Ivy, by cutting her throat with a kitchen knife at the home they shared at The Oval, Pocklington, on September 14, 2003.
He had been a loving son until he suffered a massive breakdown.
Torrie was ordered to be detained indefinitely in a secure hospital after he admitted manslaughter, also on the grounds of diminished responsibility.
The report into Torrie's case, carried out by the same organisation, said: "The root cause of this homicide was the rapid reduction of medication and the way this was managed in the absence of a risk assessment."
The findings of the reports are due to be discussed at a SHA board on Tuesday, ahead of a press conference.
However, the Mail discovered the findings on the SHA website.
Moments after we contacted the health organisations involved, the papers were removed from the website.
The board will be asked at the meeting to approve the publication of the independent investigation reports.
It will also be given the action plan by Humber Mental Health Teaching NHS Trust, NHS East Riding of Yorkshire and NHS Hull, the region's primary care trusts, drawn up in response to the findings.
The action plan includes reviewing the way the health organisations share information, reviewing staffing levels, conducting an audit of out of hours services and producing information packs for patients and their carers.
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