A report into the killing of a woman by her mentally ill son, after a row over smoking, has highlighted shortcomings in his care.

Healthcare Inspectorate Wales (HIW) has published its report following a review of the homicide carried out by a mental health service user in Pembrokeshire in 2009.

Jarvis Ford killed his 84-year old mother Margaret with a knife at their home in Templeton, on May 16, 2009. They had moved to the area from Solihull in 2007 to be nearer to other family members.

Mr. Ford pleaded guilty at Swansea Crown Court in October 2009 to a charge of manslaughter on the grounds of diminished responsibility and was detained indefinitely at a secure unit under the Mental Health Act.

The review was undertaken by HIW to ensure that any lessons that might be learnt by those organisations involved in the care, treatment and support of the individual are identified and necessary improvements made.

The report published this week, investigates the care and support provided to Mr. Ford and how this had an impact on the death of Margaret Ford.

The review has highlighted concerns in relation to the adequacy of the care and treatment provided in this case.

The findings of the report stated that while the homicide committed by Mr. Ford was not predictable, there were shortcomings in the care and treatment he received during his engagement with mental health services in Pembrokeshire.

HIW considered that the arrangements for the transfer of Mr. Ford's care from Birmingham and Solihull Mental Health NHS Trust to South Pembrokeshire Community Mental Health Team were less than optimal, and that a direct referral would have enhanced communication on risk and relapse factors.

The report noted that insufficient regard was given to Mrs. Ford's role as a carer for her son and the potential for her to require care as an elderly and vulnerable adult.

Whilst front line staff were found to have acted appropriately in the circumstances, there were significant support and resource issues facing the mental health practitioners working in the Narberth area according to the report, leading to a small team covering a wide geographical area, resulting in many of the shortcomings identified in the review.

It was also pointed out in the report that the care and treatment provided to Mr. Ford by Hywel Dda Health Board was not sufficiently robust, meaning that opportunities to develop appropriate contingency and crisis plans to manage the risks posed by relapses were missed.

It said that carers and family members had to engage in a frustrating and cumbersome process to contact various practitioners within the social and healthcare teams, and communication between these teams was also inefficient, while processes for accessing emergency mental health assessment and care were inadequate and burdensome.

Chief executive of HIW, Dr. Peter Higson, said: "This is a tragic case, but it is important to stress that incidents like this are extremely rare.

"The purpose of our investigation was to identify learning to ensure that mental health services are better able to minimise the risk of similar incidents in the future.

"While our review concluded that this homicide could not have been predicted, it has highlighted a number of shortcomings.

"Hywel Dda Health Board has prepared action plans and we are now reviewing these against the recommendations made in our report to ensure that the necessary improvements will take place," he added.

Recommendations welcomed

In a joint statement, Hywel Dda Health Board and Pembrokeshire County Council fully accepted the findings of the report and welcomed the recommendations of Healthcare Inspectorate Wales (HIW).

Mr. Trevor Purt, chief executive of Hywel Dda Health Board, said: "This was a tragic and unforeseeable event which has had a profound effect on all those involved and has shocked and saddened a whole community.

"I would like to offer my sincere sympathy and condolences to the family and friends of Mrs. Ford.

"I would also like to reassure all those who require mental health services, and the wider public, that, within the newly-established Hywel Dda Health Board, changes have already been made to address the issues raised by Healthcare Inspectorate Wales and to create more integrated health and social care services that will lead to improved health care for all our patients," he said.

Since October 1, 2009, the new Hywel Dda Health Board has taken over the responsibility for health services in Pembrokeshire and in conjunction with Pembrokeshire County Council and other agencies, they have implemented a range of changes and improvements to local mental health services, which not only respond to the key recommendations from HIW, but also aim to improve the delivery of local mental health services.

A robust, detailed action plan has been produced, which the Hywel Dda Health Board say clearly demonstrates that significant progress has already been made to address HIW's recommendations.

The new Health Board carried out a full internal investigation following the incident and has endeavoured to keep relatives informed of the process, in addition to the independent external review conducted by HIW.

Angela Watwood, head of community care commissioning for Pembrokeshire County Council. said: "On behalf of Pembrokeshire County Council, I too, would like to offer my sincere condolences to the family and friends of Mrs. Ford.

"Improving access to mental health services is a key priority for all involved. We would like to assure Mrs. Ford's family and friends, and the community of Pembrokeshire that the county council and Hywel Dda Health Board are working with all the relevant agencies to ensure that we do everything possible to prevent a similar incident happening in the future," she added.