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A series of apparent suicide attempts and killings linked to patients under the care of a mental health trust has sparked a review after worrying themes were identified.

Christian Lacey, Andrew Burke, and Sami Salem killed five people, including two children, while under the care of Mersey Care NHS Foundation Trust, while in the past 18 months three patients have fallen from the multi-story car park at Aintree Hospital.

A review conducted by Liverpool Clinical Commissioning Group (CCG) found common themes including mental health staff working alone without appropriate skills, failure to listen to the families of patients and failures to understand patient risks.

The review stated: "It is unclear if all practitioners have a formal mental health qualification. The investigation identified gaps in staff knowledge and not all staff have the skills required to function as lone workers."

In April last year Lacey, then 21, stabbed his 63-year-old mum Liz Lacey to death and tried to kill his grandmother's carer in Garston, after being assessed by a mental health crisis team and the trust's Criminal Justice Mental Health Liaison Team.

A separate report into the case found staff had missed his schizophrenia due to a "lack of professional curiosity" and an assumption he was not dangerous because he was "well dressed and from a nice family."

Lacey pleaded guilty at Liverpool Crown Court to manslaughter on the grounds of diminished responsibility, and is detained in Ashworth high security hospital.

Andrew Burke, 30, walked into the office of TUI travel agents in Southport in January 2018 and slit the throat of his ex-partner's new girlfriend Cassie Hayes, before waiting for police to arrive.

He was known to mental health services but was not found to be acutely unwell and was jailed for life after admitting murder.

Sami Salem, 30, suffocated his wife and drowned his two young children in the bath at the family home in Falkner Street, in the Georgian Quarter, while suffering from paranoid schizophrenia in May, 2017.

(Image: Twitter)

He was convicted of murder after a trial and jailed for life, but is currently also detained in Ashworth.

The review also mentioned two incidents where women left a hospital ward in Aintree and fell from the multi-storey car park.

One of the patients fell from the top floor after being admitted to A&E having taken an overdose.

Helplines and support networks If you have been affected by any of the issues discussed in this article or need to talk someone, the NHS Choices website lists the following helplines and support networks: Samaritans operates a 24-hour service on available every day of the year by calling 116 123, and an email service is available at jo@samaritans.org. Childline , on 0800 1111, runs a helpline for children and young people in the UK. Calls are free and the number do not show up in the phone bill. PAPYRUS , 0800 068 4141, is an organisation supporting teenagers and young adults who are feeling suicidal. Depression Alliance is a charity for people with depression. It does not have a helpline, but offers resources and links to other relevant information. Students Against Depression is a website for students who are depressed, have a low mood or are having suicidal thoughts. Bullying UK is a website for both children and adults affected by bullying.

The review stated that the women had already made an attempt to get to the car park but was detained by police and returned to the hospital under Section 136 of the Mental Health Act.

The review says: "The patient was treated in Accident and Emergency overnight and transferred to the Female Assessment Bay (FAB) and then to Medical Assessment Unit (MAU) to continue treatment for the overdose.

"Following an assessment by the psychiatrist from Mersey Care NHS Foundation Trust, the Section 136 was stood down. The patient subsequently absconded again to the multi storey car park, climbed to the top floor and was seen to jump from the top floor."

The second woman was seen by the mental health crisis team but then went to the car park and fell from the first floor, suffering severe leg injuries.

Since the publication of the review a third patient, a man in his 40s, also sustained serious injuries falling from the second floor of the building after being sectioned.

The review states: "The Aintree car park is a focal point in several incidents of suicide/attempted suicide and Aintree is doing remedial work on this to address it; this should be done jointly with Mersey Care mental health team input.

"The handover process for when the patient was transferred from A&E to the Mental Health Team requires clarifying; it was suggested that staff in the Mental Health Team had limited understanding of the potential risks around the patient.

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"National guidance also directs that Acute and Mental Health Trusts should work together to develop their processes."

CCG staff also found that staff had not listened to the families of the service users, and in Lacey's case they were not spoken to at all despite being in the building where he was being assessed prior to Miss Lacey's death.

The review said a number of changes are already being implemented, including new staff to work on crisis teams, closer scrutiny of risk assessments and closer working with GPs and families.

A spokesman for Mersey Care said: "We are aware of incidents involving service users at Aintree and we are conducting an ongoing review into the circumstances leading up them alongside colleagues from the Aintree University Hospital NHS Foundation Trust.

"We are unable to comment about individual patients because of rules governing patient confidentiality.

"As regards mental health assessment training of staff, a programme of improvement has been put in place to raise the skills of staff in relation to risk assessment.

"This includes both individual supervision and the delivery of a training programme."

A spokesperson for Aintree University Hospital said: “We are working closely with colleagues at Mersey Care and Merseyside Fire and Rescue to review the existing safety measures in place on the multi storey car park and to determine what further measures can be taken.”