A man who killed a support worker sent alone to visit him “could and should have been detained” under the Mental Health Act if agencies had provided more “robust” care in the weeks leading up to the attack, a report has found.
Ashleigh Ewing, 22, was stabbed to death in May 2006 during a home visit on behalf of Sunderland-based support provider Mental Health Matters.
Ewing’s killer, Ronald Dixon, who was diagnosed as suffering from schizophrenia, was detained indefinitely in a secure psychiatric unit in 2007 after admitting manslaughter on the grounds of diminished responsibility. At the time of the offence Dixon was receiving care from Northumberland, Tyne and Wear NHS Foundation Trust.
The independent review into the care and treatment of Dixon also concluded that Ewing should not have been sent alone on the home visit. But the report found it was “impossible to conclude with absolute certainty” that the “vicious attack” could have been prevented or avoided.
The report was commissioned by the North East Strategic Health Authority – now part of NHS England – following the completion of legal proceedings on the case. The review, led by a panel made-up of legal, health and social care professionals, criticised Northumberland, Tyne and Wear NHS Foundation Trust for a number of failings in the case.
A more ‘robust’ approach to the care and treatment of Dixon – particularly in the five weeks leading up to the death of Ewing – should have seen a reassessment of his condition that would have concluded he had relapsed, the panel found.
Dixon’s relapse meant he “could and should have been detained” under the Mental Health Act, the panel concluded. Even if Dixon had not been detained, visits by “lone workers would likely have ceased” in light of the deterioration in his condition.
The panel also found that, in the five months leading up to Ewing’s killing, mental health professionals had an “over-reliance” on staff at Mental Health Matters to report and interpret Dixon’s behaviour. This was despite the charity’s role in Dixon’s care being “extremely limited” and focused on providing housing support.
“Mental Health Matters staff did not have the experience to report upon presenting mental health symptomatology, let alone symptoms suggesting that [Dixon] had relapsed into a psychotic episode,” the panel found.
Moira Angel, director of nursing and quality for NHS England in Cumbria, Northumberland, Tyne and Wear, said: “The circumstances surrounding the death of Ashleigh Ewing are extremely upsetting. Our deepest sympathies are with Ashleigh’s family, who have shown much patience and dignity during the course of this investigation.”
“The final report explains in detail where the care provided to Ronald Dixon could and should have been better,” added Angel.
In a statement, Northumberland, Tyne and Wear NHS Foundation Trust said it accepted the report findings and said the “shocking and tragic” case provides lesson for health and social care agencies.
“It is important to remember that this tragic death occurred over seven years ago and much has changed since then. We would also like to reassure Ashleigh’s family and the public that since these tragic events, the trust has rigorously and continually improved the areas of care that have been found by this report to fall short of good practice,” the statement said.
In 2010, after a prosecution brought by the Health and Safety Executive, a court ordered Mental Health Matters to pay £30,000 for failing to properly protect Ewing.
Helen MacKay, CEO of Mental Health Matters, said: “Whilst I am pleased that the full picture of the care of Mr Dixon has now emerged I am also saddened in that it has taken seven years after Ashleigh’s death for the information to be made public.”
“MHM have and will continue to co-operate fully with the reviews recommended in the report to ensure the safety of health and support agency staff, service users and the public,” she added.