A PARANOID schizophrenic who stabbed to death a health worker “could and should” have been detained under the Mental Health Act, an investigation has found.
Ronald Dixon, originally from Sunderland, stabbed Ashleigh Ewing 39 times when she was sent to his home alone.
But an independent panel set up to look at the attack criticised health chiefs from Northumberland, Tyne and Wear NHS Foundation Trust and said Dixon should not have been managed in the community.
Dixon was described in a report commissioned by the North East Strategic Health Authority as a loner who had a history of mental illness. He had previously attacked his parents with a hammer while they were in bed at their home in Shakespeare Street, Southwick.
He received two years’ probation for that offence and voluntarily attended Cherry Knowle Hospital in Sunderland for treatment.
The report outlines how by 2006 when he killed 22-year-old Ashleigh, he had relapsed and “probably could and should have been detained under the Mental Health Act”.
And even if he was not detained, the panel found that a more robust care plan would have been in place, and Ashleigh would not been alone with her killer.
The report goes on to say whether this would have prevented the attack is “a matter of speculation”.
Psychology graduate Ashleigh, who worked for Sunderland-based housing support charity Mental Health Matters (MHM), was sent to Dixon’s Newcastle home on May 19, 2006, with a letter telling him he was in debt.
Within 15 minutes of her walking through the door, a neighbour heard screams and shouts of “get off” and “stop it”. A minute-long “hysterical screech” was then heard, before Dixon changed his bloodied clothes, showered and, with his dogs, walked to a police station and said he had murdered someone.
The report said: “It is the view of the panel that if a robust risk assessment had been completed including a consideration of the lone working policy with P (Dixon), such lone working would have been abandoned and joint visits implemented. Thus, it must follow, that A (Ewing) would not have been attending P’s (Dixon’s) house on her own.”
Experts concluded it was “misguided and inappropriate” that Dixon’s care was based on information supplied by MHM and there had also been “a fundamental failure of communication” between consultants involved with Dixon’s treatment and care.
The panel also found MHM staff did not have sufficient training or skills to assess and reliably report on Dixon’s “mental stability.”
A spokesman for MHM, which has previously admitted health and safety breaches and been fined £30,000, said: “MHM acknowledged from the outset that there had been failings in its procedures regarding risk assessment and admitted those failings at both a Health and Safety Executive prosecution and the inquest into Ashleigh Ewing’s death.
“We have conducted a thorough review of our procedures and have strengthened our risk assessment and staff safeguarding practices.
“We are eager to co-operate fully with the reviews recommended by the report to ensure the safety of health and support agency staff, service users and the public.”
A spokesman for Northumberland, Tyne and Wear NHS Foundation Trust said: “We welcome publication of this report, we accept its findings and we apologise for the shortcomings identified in it. We particularly extend our sincere apologies and our condolences to the family and friends of Ashleigh Ewing.
“This was a shocking and tragic incident, which provides lessons for all the agencies involved and for the wider health and social care systems.”
In October 2007, Dixon pleaded guilty to manslaughter on the grounds of diminished responsibility and was ordered to be detained indefinitely in a secure psychiatric unit.
Recommendations by expert care panel to improve policy
THE mental health trust should review its assurance arrangements to ensure that all staff consistently follow care programme approach policy.
•All professionals involved in the care programme approach have a responsibility to ensure individual and team compliance.
•The trust should amend existing (care programme approach) policy framework to provide a clear and measurable assurance system.
•The trust should formally review its risk assessment and management learning framework to ensure (it takes into account) a clear consideration of records of previous significant events, behaviours and influences, along with their cumulative effect. An assurance framework must be established to monitor the impact of this.
•There should be greater inter-agency role clarity. In particular, the specific role of outside agencies should be clarified and documented within a patient’s records so that there is a clear understanding between a clinical team and outside agencies as to the role each has to play.
•The care programme approach policy framework issued by the trust’s corporate management to line managers and staff should be followed consistently. It is of particular importance to monitor and ensure, by way of regular audit, compliance with policy on a continuing and enduring basis.
•There should be a review of the effectiveness of communication systems in place between the trust and other agencies involved in care provision using the care programme approach framework.
•There should be a review of the compliance with and the effectiveness of lone worker’s safety procedures, in particular having regard to the reliance that outside agencies may place upon the assessment of risk by clinical teams.
•That there should be a review of the internal reporting in relation to serious untoward incidents.
In particular, the trust should seek to ensure that root cause analysis remains the focus of such internal investigations, which should be carried out robustly so as to ensure that failures are highlighted as soon as possible.