Image above: West London Coroner’s Court; photograph Nigel Cox
Uncaring ‘care in the community’ contributed to woman’s death
The Assistant Coroner for the Western Area of London, Dr Séan Cummings, has criticised the North West London NHS Foundation over the death of a woman who was stabbed to death by her housemate, and warned that more deaths could happen if they don’t take action.
Bathsheba Shepherd was killed by a young man with a history of violence who was moved into her home with no regard for her safety, despite clear and repeated evidence that he was a threat to her. Bathsheba Shepherd, known as Kay to her family, was killed in November 2015; her inquest took place in September 2020.
In his report, Dr Cummings said Kay, a middle-aged woman who suffered epileptic fits, was housed with a young man with paranoid schizophrenia and a cannabis or skunk dependence. They were both ‘extremely vulnerable individuals’.
The house they shared had two bedrooms, one living room and kitchen and one bathroom. There were problems with the heating and hot water system which caused escalating tension between the two.
Kay should have had a GP
Although she had visiting support workers, Kay did not have a social worker or care coordinator; neither did she have a GP because she needed ID to register and she declined to apply for a passport on the ground of cost.
‘The failure to have a GP meant that the source of any medication supply for her epilepsy was uncertain and I feel that it was overwhelmingly likely that she wasn’t being treated at all for her epilepsy’ the coroner wrote.
‘Not being treated put her at risk of physical injury occasioned through any fits and amounted to a significant gap in care and support offered. Not having a GP represented a missed opportunity to intervene in terms of her mental health.
‘In my view a much more assertive approach to this was required to ensure she was registered but it appears that without formal identification GP practices will not register individuals’.
Violent man moved into Kay’s home without concern for her safety
Kay was already living at the property when the Accommodation Panel approved the decision to move the young man in with her. He had been living in a psychiatric facility before moving into the house where he killed her.
Although he had been an inpatient for 15 months, neither a full psycho social assessment was undertaken nor a NHS and Community Care Acts needs assessment, the tools which are usually used to identify patients’ needs and to assess risks.
The Senior Support Worker ‘did not enquire as to the history of aggression’ before referring him to the landlord which, Dr Cummings says, was an error.
‘There is no documentary evidence of Kay being asked as to her views’ on the young man moving in.
‘There was clear and repeated evidence during stay in hospital between 31 July and 24 August 2015 of his distress at his living arrangements and that he posed a threat to Kay’s physical safety.
‘Despite this I gained the distinct impression that staff were more concerned about risks posed to them than those posed to Kay.
‘Indeed, Kay and her safety and security do not feature in the discussions or plans to ensure safety. It was as if she was not there’.
Forced to live with ‘an extremely dangerous young man’
‘The failure to expeditiously rehouse and to effectively risk assess him and manage those risks in the time between discharge from hospital and Kay’s death meant that she was living with and ultimately killed by an extremely dangerous young man who had himself recognized that he should not return to (the address, redacted) and had expressed his dislike of his flat mate to clinicians and asked to be placed elsewhere’.
The coroner’s report, which has been sent to the Chief Executive of the Central and North West London NHS Foundation and the Chief Executive of NHS England, flags up that future deaths could occur unless the health authority sorts out better liaison between the local authority (Hillingdon) and the NHS Trust.
A full five years after Kay’s death:
‘the issue of the way in which the Care Programme Approach was being conducted between the local authority and the NHS Trust was still the subject of discussion.’
It had not been resolved to the satisfaction of the manager responsible for the process.
Dr Cummings also says there must be action taken so that people like Kay can register with a GP.
‘Registration with a regular GP would in my mind have provided additional support to her. This may have enabled her to raise concerns or fears relating to her accommodation and housemate’.
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