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31 August 2011, 11:05 | Updated: 30 March 2016, 13:50
A review has found there were shortcomings in the care received by a mental health patient who killed four members of his family in Newcastle.
David Bradley, a heavy cannabis user who served as a soldier in the first Gulf War, shot his uncle Peter and aunt Josie Purcell, both 70, and their sons Keith, 44, and Glen, 41, five years ago.
An independent study found it could not have been predicted that Bradley, who was receiving community health care from Northumberland, Tyne and Wear NHS Trust (now Northumberland, Tyne and Wear NHS Foundation Trust), would kill.
But the panel made 17 recommendations after finding that: risk issues were identified but never dealt with in any systematic way; there was a lack of adequate record keeping and communication; and his treatment was not in accordance with national guidance on care co-ordination and the multi disciplinary care programme approach.
He flipped and killed his family with a handgun he smuggled back from Bosnia, then calmly handed himself in to police.
At Newcastle Crown Court in 2007 when Bradley admitted manslaughter on the grounds of diminished responsibility, it was said that the recluse may have been suffering from Post Traumatic Stress Disorder but it was agreed he did not have Gulf War Syndrome. Bradley was sentenced to life imprisonment to serve a minimum term of 15 years. He was sent to Rampton Hospital for treatment.
Professor Aidan Mullan, director of nursing, patient safety and provider development at North East Strategic Health Authority said:
'First and foremost, our deepest sympathies go to the extended family of Mr Bradley. This appalling incident has undoubtedly been particularly harrowing for them and there are absolutely no excuses for the shortcomings in the care that was provided to David.
'We commissioned this independent investigation to get a clear picture of David's interaction with health services, to understand where things can be improved and most crucially, to ensure that lessons can be learned and shared throughout the NHS to prevent similar incidents from occurring. It is important to note there have been vast improvements in mental health care since 2006.'
Euan Duff, the barrister who led the inquiry, said:
'At the end of the investigation we found that, whilst it is evident that the final catastrophic outcome could not have been predicted by any professional involved in David Bradley's care, there were a number of shortcomings in the care with which he was provided at various stages.'
Northumberland, Tyne & Wear NHS Foundation Trust said it has appointed a specialist Veteran's Nurse Consultant in partnership with the charity Combat Stress to help develop specially tailored treatment options for patients with PTSD.