Statement following the publication of report commissioned by NHS England

Statement following the publication of report into the deaths of Kenneth Godward and Roger Lamb, and the care provided to Harry Bosomworth

Harry Bosomworth, a 70-year-old gentleman, attacked and seriously injured Ken Godward and Roger Lamb on ward J19 at Leeds Teaching Hospitals Trust on 28 February 2015. All three patients died within six months of the incident.

This statement has been published in response to two reports that investigated the circumstances surrounding this incident and the recommendations they make. Those reports were:


  1. A report by David Curtis jointly commissioned by Leeds and York Partnership NHS Foundation Trust (LYPFT) and Leeds Teaching Hospitals NHS Trust (LTH) which reviewed the care and treatment provided to Harry Bosomworth, published in April 2016.


  1. A report commissioned by NHS England entitled “An independent investigation into the care and treatment of Harry Bosomworth by Leeds and York Partnership NHS Foundation Trust and Leeds Teaching Hospitals Trust” published on 18 December 2018. This report has also been published on NHS England’s website.


LYPFT has published an assurance statement on actions it has taken in response to these reports which can be found on its website.

Photo of Trust Chief Executive, Dr Sara MunroIn response to the report, Dr Sara Munro, Chief Executive at Leeds and York Partnership NHS Foundation Trust, said:

“This was a very rare and tragic incident, and we would like to reiterate our sincere apologies and condolences to all the families affected by it.  We understand that this has been an extremely difficult and upsetting time for everyone involved. We also recognise that it has taken a long time for us to get to this point which is far from satisfactory for the families.

“We have co-operated fully with the coroner’s inquest which concluded on 17 December 2018, as well as the two independent reviews which investigated the tragic deaths of Mr Godward and Mr Lamb and the care received by Mr Harry Bosomworth. The first review was jointly commissioned by us and Leeds Teaching Hospitals and was completed in April 2016. The second was commissioned by NHS England was published on 18 December 2018.

“We agreed the terms of reference for both reviews in line with the national serious incident framework and with all relevant partners, including NHS England, Leeds Teaching Hospitals and Leeds Clinical Commissioning Group.

“We respect the opinion of the authors of the second independent review. Many of their recommendations concur with those in the original independent investigation conducted by David Curtis.  We do not, however, believe the staff involved could have predicted this incident would occur. This was upheld by the coroner in his conclusion following the inquest.

“Incidents of this nature are extremely rare. Our view on predictability and preventability is based on extensive research on incidents of violence amongst people with serious mental illness, which is much lower than that found in the general population.

“We take our responsibility to implement the recommendations from both reviews seriously and ensure the care we provide is safe and effective. There have been a number of positive improvements and changes to practice that we and our colleagues at Leeds Teaching Hospitals have made. Some of these were already in progress at the time of the tragic incident in February 2015, and some were a result of the learning from it and recommendations from the reviews.

“We have significantly enhanced our Liaison Psychiatry Service – which offers vital mental health support to patients in the acute hospitals as well as expertise to the staff working there. We have recruited additional staff, including senior nurses and social workers, and we now offer a fuller range of Liaison Psychiatry Services 24 hours a day, seven days a week, in line with national standards and increasing demand. However I want to make it clear that our liaison services were in no way short staffed at the time of the incident.

“We have improved the way we share records with our colleagues in the acute hospitals, including risk assessments, medication information and guidance on managing patients with complex needs. This means that patients with both mental health and physical health needs can be cared for in a more joined up way.

“We set up joint working groups with Leeds Teaching Hospitals in 2016. These forums have helped us to implement recommendations from the reviews, and also continuously improve the day-to-day delivery of physical and mental health services for hospital patients in Leeds.

“I know all these improvements will not change what happened, but I hope they go some way to help the victims’ families understand how we’ve learned and changed things for the better.”

A full summary of the actions taken by LYPFT in response to recommendations from both reviews can be found on its website.