Senior coroner Derek Winter was speaking at the conclusion of an inquest into the circumstances surrounding her death at Sunderland Coroner’s Court today, Friday, May 6.
Mountain attacked Mrs Hoggett while she was at work in the One Stop Shop, in Sea Road, Fulwell, on September 5, 2018.
Police and paramedics fought to save her but she was pronounced dead at Sunderland Royal Hospital shortly before midnight.
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Nineteen-year-old Mountain, of Heaton Gardens, South Shields, accepted responsibility for her death and was made subject to an an indefinite detention order at Newcastle Crown Court in March 2019.
He had originally been accused of Mrs Hoggett’s murder but a judge directed the jury to find him not guilty after both prosecution and defence teams accepted he was suffering an abnormality of mind at the time of the killing, which impaired his responsibility.
The inquest has been examining the support Mountain received from the Cumbria, Northumberland and Tyne and Wear NHS Trust between his release from hospital in 2017 and the attack on Mrs Hoggett.
The hearing heard Mountain had been referred to mental health services and had entered hospital, initially voluntarily, in June 2017, but was later sectioned before being released after appealing to a mental health tribunal in August.
The trust has originally opposed his release but subsequently agreed to it on the basis it would maintain contact with Mountain. Mr Winter said it was possible he had been more unwell than appeared to be the case: “I note that Ethan Mountain was knowledgeable about mental health conditions and appears to have undertaken research,” he said.
"It may well be that he was able to mask the true extent of his condition even with professionals, which may have impacted their decision making. His overall recovery was perceived as remarkable but there was little evidence of that being challenged.”
Mountain had been placed under the care of the Trust’s early intervention team and prescribed anti-psychotic mediation. He had initially been co-operative and he and his mother has taken part in two family therapy sessions.
In February 2018, he had expressed a wish to reduce his medication with a view to giving it up altogether and this had been agreed on the basis that a lower dose was preferable to him simply ceasing to take anything at all.
It was agreed a temporary period of increased monitoring would be put in place to see what effect, if any, the reduction had: “This increased monitoring did not happen” said Mr Winter.
Ethan had last been seen by care co-ordinator Christopher Laydon on April 10 and efforts to arrange subsequent appointments had been unsuccessful.
"This was the last time the Trust engaged with Ethan Mountain – 148 days before he killed Joan,” said Mr Winter.
Mr Laydon had met with supervisor Claire Pickard in June and August but Mountain’s clinical care records had not been checked: “Claire Pickard was still not aware that the family therapy had not progressed since March 7, 2018,” said Mr Winter.
"Ethan Mountain had still not seen seen since April 10, 2018.”
Mountain’s mother Nicola Curtis has telephoned Mr Laydon on August 28, as he was about to go on annual leave, to request an appointment. He had not mentioned it in his hand-over note, intending to call her upon his return.
"In my view, this call by Ethan Mountain’s mother was significant, whether it was a simple request for a return call or whether she went into any detail about the reasons for her call, it was her reaching out, after a considerable period, to the person who knew the detail about the son, unlike other services she may have called,” said Mr Winter.
By the time he attacked Mrs Hoggett, the Trust did not have ‘any ongoing situational awareness’ about Ethan Mountain, said Mr Winter: “Its approach was to assume that in the absence of adverse reports, all was well.
"This was a passive, rather than a proactive approach to the healthcare and treatment of Ethan Mountain. Information was not always gathered or corroborated.
"To some extent, the Trust were reassured, but in reality, there was no substance to that belief.
"Ethan Mountain became invisible to the services that he could have tapped into.”
Nicola Curtis had raised concerns but these had not been taken seriously enough: “In my view, the Trust were too ready to put her concerns about him being depressed, his medications, his drinking, her fear of relapse, down to her hypervigilance,” said Mr Winter
The inquest had been told that the trust had carried out its own internal investigation, had been subject to an independent peer review and was currently under review by specialist Niche on behalf of NHS England.
A large number of improvements had been introduced but Mr Winter said he remained concerned about the situation locally and nationally.
"Although the Trust had recognised the shortcomings of some of the operation aspects of the healthcare and treatment provided to Ethan Mountain, and focusing as I must on the current position, I remain concerned,” he said.
"I know that the Trust are committed to learning and that this case has had a profound effect on everyone involved, family and professionals, but I do have some residual concerns.”
Recording a conclusion that Mrs Hogget had been unlawfully killed, he said he would be writing to the Trust and asking them to reflect further on ‘enhancing the involvement of family members’ and Health Secretary Sajid Javid about ‘the capacity of mental health trusts to meet demand, together with staff resilience and contingencies’.
Rajesh Nadkarni, Executive Medical Director at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust said: “We would like to offer our deepest sympathy to Joan’s family at this incredibly difficult time.
"The tragedy of Joan’s death has had a significant impact on the team, the service and what we do as an organisation. We have been determined to learn lessons and improve services.
“The organisation has made substantial changes following the incident. This includes revisions to the clinical supervision policy which now require supervisors to review clinical records to provide greater reassurance.
“New documentation has also been introduced which require improved scrutiny around risk assessments, non-engagement as well as engagement with services, families and carers.
“These policy changes are now fully implemented across the organisation, with training rolled out to our staff in February 2020.
“Although nothing can ever ease the pain of losing Joan, we sincerely hope that the knowledge that lessons have been learned and changes are in place will offer some comfort to her family.”