The investigation came after a 31-year-old man stabbed a man in his thirties in November 2020, just one month after being discharged from the care of Kent and Medway NHS and Social Care Partnership Trust, now called Kent and Medway Mental Health NHS Trust.

Rebecca Hilsenrath, chief executive of PHSO, said the case highlighted ‘stark consequences of poor mental health care, not just for patients, but also for their families, carers and even members of the public', adding: ‘There is still significant work to be done to embed a culture within mental health services that learns from past mistakes. While there have been some improvements, including steps towards reform of the Mental Health Act and ongoing Government inquiries, these must lead to real change on the ground – change that improves services and keeps people safe.'   

The investigation was launched after patient's mother, 57, complained about the care and support the trust provided to her as she tried to get help for her son. 

The ombudsman found the trust had failed to develop a care plan or crisis plan and did not provide information or support to his mother as his designated carer. 

PHSO recommended the trust writes to the woman to acknowledge the failings in her son's care, the lack of support provided to her as his carer and the serious distress and anxiety this caused. The ombudsman also recommended the trust creates an action plan to improve its services. 

The trust was also asked to pay the mother £240 for costs to repair property damage when her son was in crisis in May 2020, as well as £3,700 in recognition of the long-term distress and worry caused by its lack of support. The trust has agreed to comply. 

A Kent and Medway Mental Health NHS Trust spokesperson said: ‘This was a deeply serious and complex case, and we recognise the distress experienced by the family. 

‘Concerns raised in 2021 were fully investigated, including through close engagement with the Parliamentary and Health Service Ombudsman, and we have been open and transparent throughout that process. 

‘We apologise for where care and support did not meet expected standards and have taken action to strengthen community mental health services in line with the National Community Mental Health Framework.'