Harrison inquiry says danger is still present

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Catastrophic failings in the care of a mentally ill man who attacked and almost killed the former Beatle George Harrison nearly three years ago have still not been addressed and could lead to a similar incident at any time, an independent inquiry said.

Despite two internal inquiries by the St Helens and Knowsley NHS trust into the incident, in which the multimillionaire musician was stabbed in the chest 10 times while his wife, Olivia, tried to fight off their attacker at their mansion in Henley-on-Thames, Oxfordshire, the measures taken to prevent a repeat of the incident have been inadequate, the three-member panel said.

The intruder, Michael Abram, 35, who had travelled from his home in Liverpool to assault Harrison on 30 December 1999, had a 10-year history of mental and drug problems and had repeated fantasies that rock bands including the Beatles and Oasis were trying to communicate with him through their music.

But despite repeated hospital admissions, and a diagnosis of schizophrenia aggravated by drugs, Mr Abram was allowed to drift in and out of touch with the mental health services. "This illness had not been treated for any substantive period prior to the assault, despite many contacts by Michael with the mental health and drug services in Knowsley over a period of years," the inquiry report said.

The inquiry accepted, however, that the attack could not have been predicted because Mr Abram had no history of violence and had given no warning that he intended to assault the musician. The St Helens and Knowsley health authority and NHS trust jointly apologised yesterday to the Harrisons and to Mr Abram and his family for the failures in his treatment "prior to the appalling events of 30 December 1999" and accepted the 22-point action plan recommended by the inquiry panel.

Mr Abram, who is detained under the Mental Health Act at the Scott psychiatric clinic in Railton, Merseyside, said yesterday: "The report is good in many ways. It shows where the system failed but I am disappointed that it does not identify several individuals who let me down. I had a serious mental illness but nobody listened. Everybody thought they knew me but nobody listened."

At the end of his last hospital admission, six weeks before the attack, Mr Abram was discharged without any diagnosis of mental illness, or any prescription for medication, because doctors were ignorant of his medical history. The inquiry report said he was inadequately assessed, described his discharge as "unacceptable" and criticised arrangements made for follow-up.

The central failure was the lack of any care plan for Mr Abram. "Our real concern is that the changes in practice undertaken by key agencies since the incident have not completely addressed the key problems. This means that the pattern of events could recur at any time. These concerns were immediately brought to the attention of the chair and chief executive of the health authority," it says.

The report is scathing of the trust board, saying it failed to implement satisfactory controls after the internal inquiries to see that recommendations were acted on and that it failed to rectify the lack of support for mental health services. The health authority and trust said no one would lose their job over the blunders exposed in the inquiry report and that the "system failed" rather than individuals. Ken Sanderson, chief executive, said the trust accepted the criticism and was working to ensure "past mistakes are not repeated".