A man with mental health problems and a history of violent threats killed a woman in Devonian Park after falling off the waiting list to see a care coordinator, possibly because the health trust's computer records were compromised in a cyber attack, an investigation has heard.
If Cameron Davies had been assigned a care coordinator, a multi-departmental meeting could have been called on it. before he stabbed 74-year-old Lorna England to death– concluded senior coroner for Devon, Plymouth and Torbay Philip Spinney.
Spinney also highlighted that on the day of the murder, a mental health nurse tried to contact police on the non-emergency 101 line to report that Davis had threatened to kill someone. The nurse waited on the line for about two hours before it was disconnected.
The investigation heard that Davis had been known to Devon mental health services since November 2021.
In January 2023, a month before the murder. Englandhe turned up at Exeter police station and told the officer he would “100%” kill someone. He was taken to hospital but released.
On Saturday 18 February, the morning of the murder, he told the paramedic that he would kill “a random person” if he was not apprehended. He was taken back to hospital but discharged again and continued his attack on England that same day.
The coroner said mental health teams followed the correct procedures in deciding not to detain Davis. But he said: “There was an error in 2022 when Mr Davis was removed from the waiting list. Mr Davis was not assigned a care coordinator.”
He said: “I have concluded that Mr Davies would greatly benefit from having a care coordinator as a single point of contact, as do other agencies involved in information sharing.
“The Care Coordinator may have called a multi-agency meeting following Mr Davis' mental health decline in late January. [2023]”
Spinney said a community mental health meeting scheduled for Feb. 20 — two days after the killing — may have been rescheduled.
The coroner said a consultant psychiatrist suggested Davies may have “fallen off the radar” because Devon Partnership NHS Trust's computer records system was corrupted, preventing access for several months. The psychiatrist said it was caused by a cyber attack on a company that provided software to the National Health Service.
The coroner went on to say it was “clear” the 101 service was not operating effectively on the day of England's murder. He said a call from a mental health nurse indicated there was a “glitch” in the system.
But the coroner said he could not say that if Davis had been given a care co-ordinator or the 101 service had worked better, England's murder would not have happened.
Holly Mackley from HCC Solicitors, who assisted the family, called for changes to the way potentially dangerous people are treated in society. Mackley said: “Why were police, medical staff and housing agencies not involved in the multi-agency risk meeting regarding Davis?”
A Devon and Cornwall Police spokesman said: “We will carefully examine and consider each of the findings in detail.” Devon Partnership NHS Trust declined to comment on the care coordinator issue.
Davis was jailed for a minimum of 28 years. The coroner concluded that England was killed unlawfully.
