After the attacks of June 2023, a series of work was done to understand the incident, including a thematic review of homicides and attempted homicides, the inquiry heard.
Recommendations made as a result of that review included rewriting policy around serious incidents, and an audit designed to identify patients who had been discharged following disengagement.
Devlin accepted those were steps that should have been taken earlier.
Inquiry barrister James Weston said: “The trust were aware, and the board were aware of the concerns with risk assessments, potential issues with discharge by September 2022
“You’ve said these policies should have bene reviewed. Had that opportunity been taken, these policies would have been in place, or some learning would have been in place long before June of 2023.”
“Yes, some learning would’ve been,” Devlin said.
Weston said: “If there’d been an audit of unsafe discharges – as I think you would agree should have happened in 2022 – that process would have picked up VC’s case wouldn’t it?”
“Yes, I expect it would have done,” Devlin replied.
Weston said: “And steps taken, to avoid the attacks in June of 2023?”
“It may be the case, yes,” Devlin replied.