Ken Godward, 76, and Roger Lamb, 79, died after they were beaten with a walking stick by 70-year-old Harry Bosomworth in St James’s University Hospital, in Leeds, in February 2015.
Mr Lamb is reported to have been trying to help Mr Godward when he was fatally injured.
An investigation report leaked to the Health Service Journal (HSJ) details how Mr Bosomworth, who had been treated for paranoid schizophrenia since 1980, was admitted to the hospital suffering from oesophageal cancer.
It explained how a decision was taken to stop the anti-psychotic drug Olanzapine, despite warnings from the patient’s family, by clinicians who were more focused on his complex physical needs than his mental health.
The report said that during the night of February 27 and 28, Mr Bosomworth was given a sedative “with the assistance of security staff as HB was kicking and punching staff when they were caring for his needs”.
Later that morning, the report said, “staff discovered HB had assaulted fellow patients RL and KG with his walking stick”.
Mr Godward suffered facial injuries and Mr Lamb was found lying on the floor with a fractured neck and leg and both pensioners died later.
Despite concluding that “it has been difficult to identify a single root cause for this incident”, the report found there had been a number of contributing factors, including not listening properly to Mr Bosomworth’s family and a “lack of assertive, structured, co-ordinated and integrated mental and physical healthcare”.
It said: “The decision to stop his Olanzapine was taken from a narrow physical health perspective and without any reference to the impact of stopping the Olanzapine on HB’s overall mental health and long-standing schizophrenia.”
The report said: “We would suggest that if they had spoken to the family in more detail, they would have obtained a more accurate and comprehensive picture of HB’s mental health needs.”
It concluded: “The low level of basic knowledge of acute medical staff of the needs of people with comorbid mental health issues in acute hospital settings has been recognised as a national issue and was a contributory factor in this case.”
Mr Bosomworth died of his cancer in July 2015, the report said.
Mr Godward’s stepson Andrew Dixon told the HSJ: “We feel as though we have been taken for a ride.”
Mr Dixon said: “We want something put in place that is going to protect people like Ken.”
The report said the ward where the attack happened is a medical ward specialising in diabetes care but “often has a high percentage of older people with a wide range of medical conditions that also present a range of challenging behaviours”.
An appendix to the report details more than 40 incidents of violent and aggressive behaviour on the ward between April 2014 and March 2015 including nurses being punched, a patient throwing a table across the room and another slamming a medicine cabinet lid on a staff member’s fingers.
Dr Nick Scriven, president of the Society for Acute Medicine, said: “This is a shocking case that has gone unreported since 2015 and it forces us all to look at how and where we treat some of our most vulnerable patients.”
He said: “We need a total rethink on how and where we can meet these people’s physical and mental needs and trusts must be open and honest in the future around this area and investigate and report this type of incident openly.”
Dr Yvette Oade, Chief Medical Officer at Leeds Teaching Hospitals NHS Trust said: “I would like to reiterate my sincere apologies to all the families involved in this tragic incident. We understand that this has been an extremely difficult and upsetting time for everyone involved and we are sorry that we let these patients down.
“Following the outcomes of an independent investigation which we commissioned in May 2015, in partnership with Leeds and York Partnership Trust, we have made a significant number of improvements to how we care for patients with challenging behaviours and mental health needs. These improvements have led to a substantial reduction in the number of incidents reported.
“Some examples of the improvements made include:
* Better integrated healthcare records so we can share information about individual patients with staff at the mental health trust;
* Availability of a specialist mental health practitioner within our hospital to provide urgent new protocols in place around accessing the early opinion of a consultant psychiatrist;
* Clear procedures to ensure an early opinion of a consultant psychiatrist in a patient’s care;
* Development and implementation of a risk assessment tool to help staff to determine on admission the level of observation and supervision a patient requires;
* Appointment of a lead nurse for the older adult in Leeds Teaching Hospitals Trust to address how our services are provided to meet the needs of this growing group of patients.
“At all stages of the investigations, including the ongoing review by NHS England, the trust has been open and cooperative sharing information with partners and the families involved. We are continuing to work with our partners to ensure that we provide the best possible care for patients with mental health needs in our hospitals.”
Stephen Buckley, Head of Information at Mind, the mental health charity, said: “This is a terrible incident and our thoughts are with the victims’ loved ones. It’s important to get to the bottom of why such a thing happened and whether anything could have been done to prevent it.
“It must be stressed that these sorts of incidents are extremely rare. Around 1 in 4 of us will experience some kind of mental health problem this year and the overwhelming majority of people with mental health problems are not dangerous. The majority of homicides are committed by people who don’t have mental health problems.
“We know that mental health services are really struggling at the moment and that some people aren’t getting the help they need. We need to improve services so that everyone experiencing a mental health problem gets help when they reach out and ask for it.”