Man killed stranger in Devon park after losing mental health support, inquest heard | crime
A man with mental health problems and a history of making violent threats killed a woman in a Devon park after being dropped from a care coordinator waiting list, possibly because health trust computer records were compromised by a cyberattack, an inquest has heard.
If Cameron Davies had been allocated care co-ordinator, a multi-agency meeting might have been called about him before he stabbed Lorna England, 74, concluded Philip Spinney, chief coroner for Devon, Plymouth and Torbay.
Spinney highlighted that on the day of the murder, a mental health nurse attempted to call police on the 101 emergency line to report that Davis was threatening to kill someone. The nurse waited on the line for about two hours before he was hung up on.
The inquest heard that Davis was known to Devon mental health services as of November 2021.
In January 2023, a month before he killed England, Davis presented himself at a police station in Exeter and told an officer he would “100%” kill someone. He was taken to hospital but released.
On Saturday 18 February, the morning of the murder, he told a paramedic that he would kill “some random person” if he was not arrested. He was taken to hospital but was discharged again and continued to attack England that afternoon.
The coroner said psychiatric teams followed the correct procedures in deciding not to detain Davis. But he said: “An error occurred in 2022 when Mr. Davis appeared to be removed from the waiting list. Mr. Davis did not have a dedicated care coordinator.”
He said: “My conclusion is that Mr Davis would have benefited greatly from a care coordinator as a single point of contact as well as other agencies involved to share information.
“The care coordinator may have held a multi-agency meeting following Mr Davies’ mental health deteriorating at the end of January [2023]”.
A community mental health meeting scheduled for February 20 — two days after the killing — may have been brought forward, Spinney said.
The coroner said the consultant psychiatrist speculated that Davis had “flyed under the radar” because the NHS Devon Partnership’s computer records system was damaged, preventing access to it for several months. The psychiatrist said that was it Caused by a cyberattack on a company providing software to the NHS.
The coroner went on to say that it was “clear” that the 101 service was not operating effectively on the day England was killed. He said the call made by the mental health nurse showed there was a “system failure”.
But the coroner said he could not say that if Davis had been designated as care coordinator, or that the 101 service had worked better, England’s murder could have been prevented.
Holly Client of HCC Solicitors, who was assisting the family, called for changes to be made in how potentially dangerous individuals are dealt with in the community. My client said: “Why were the police, clinical staff and housing agencies not involved in the multi-agency risk meeting about Davis?”
A Devon and Cornwall Police spokesman said: “We will carefully review and consider all findings in detail.” The NHS Devon Partnership declined to comment on the care coordinator case.
Davis was imprisoned for at least 28 years. The coroner concluded that England was unlawfully killed.