Mental health care failures in triple killer case

Mental health care failings saw a man released from custody before he killed three people, a report has found.

The multi-agency report detailed how Alexander Lewis-Ranwell had set fire to a hospital ward containing other patients before he was released.

Staff, who described it as a "hostage-taking incident", said police declined to attend until normal working hours as it "was not urgent" and he "was safe".

Devon and Cornwall Police said it had acted on the learning from the review.

Lewis-Ranwell, referred to as Mr A in the review, was a paranoid schizophrenic who had been sectioned twice previously.

Despite concerns about his behaviour, Lewis-Ranwell was arrested and released on police bail twice in the 48 hours before killing three elderly men in Exeter in February 2019.

He was later found not guilty of murder due to insanity.

The review, jointly commissioned by NHS England and the Torbay and Devon Safeguarding Adults Partnership (TDSAP), was released on Tuesday.

It stated "there were visible gaps in the way the system worked in a joined-up way that allowed Mr A to be released when his mental state was relapsing".

The report detailed how on 16 June 2016 Lewis-Ranwell set fire to a wardrobe in his north Devon hospital room.

When the fire alarms sounded "he blocked the exit from the ward and then barricaded himself and other patients into the ward lounge" in what staff called a "hostage-taking" incident.

Police did not attend at the time of the incident as Mr A "was in a safe space", the report said.

Six weeks later a consultant contacted police claiming the incident was "pre-meditated and calculated", despite Mr A suffering from psychotic symptoms at the time.

The consultant said Lewis-Ranwell "would learn that he could get away with such behaviour" if criminal proceedings did not follow.

But the report said there was "insufficient follow-up" with the police by trust staff about any criminal charges.

The review also detailed how at one point a hospital changed Lewis-Ranwell's diagnosis without explanation in his records and released him twice into the community without oversight of his "long-term needs".

When Lewis-Ranwell moved to France in 2017 Devon NHS Partnership Trust discharged him from mental health after care - without evidence he no longer needed after care and against the Mental Health Act Code of Practice.

The report concluded that it was the combination of these elements that led to his release from police custody in February 2019, where he had been held for wounding a farmer with a saw.

It was then that health staff made "decisions based on incomplete knowledge of Mr A's mental health history", the report said.

It added: "The [forensic medical examiner] had to assess what was before him.

"The lack of access to previous history seems to make protecting the public and caring for/treating a man such as Mr A incredibly difficult for those charged with that duty."

The review also looked at systems in place for health care services provided to detainees, which it said were commonly outsourced to independent healthcare providers.

In Devon and Cornwall, custody healthcare is delivered by G4S, which includes a healthcare professional (HCP) who may be a registered nurse or paramedic and forensic medical examiners, who are available on-call.

The report writers made 17 recommendations, including improving access to clinical history and other agency records.

Paul Northcott, independent chair of TDSAP, said there had been a "clear commitment by the agencies involved in these tragic cases to address the learning identified in the report and improve frontline operational practice".

Mr Northcott said many of the changes had already been implemented.

Devon Partnership NHS Trust's chief nursing officer, Chris Burford, said the trust welcomed the findings and that it had engaged with them fully.

"We have worked closely with all of the agencies involved to identify opportunities for learning and improvement and to address the recommendations that have been made following these very sad deaths," the officer added.

Devon and Cornwall Police said it had also acknowledged and acted upon the report's findings.

A statement from the Lewis-Ranwell family's solicitor said while they had co-operated with the report, they could not accept or agree with its findings.

"It is their view that the reports did not encompass a full review of all relevant material nor the proper engagement of all relevant stakeholders, and therefore the conclusions reached are based upon only a partial investigation," it said.

A spokesperson for G4S Health Services Limited said: "The recommendations in the review have been considered carefully and are being implemented where appropriate."

The review has been published as Lewis-Ranwell awaits a judgement following a Court of Appeal hearing last month.

He is seeking compensation for alleged failures, claiming he should have been assessed under the Mental Health Act while in custody and if that had happened, he would not have been released and would not have killed his victims.

He claims the four agencies were negligent for not having him assessed under the act.

The agencies involved dispute this and want the damages claims against them struck out.

The court has said there was no timeline for when the judgement would be handed down.

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