Failings contributed to three killings, jury finds

A series of police and healthcare failings contributed to the deaths of three elderly men killed by a man suffering a psychotic episode who was released from custody hours before the killings, a jury has found.

Alexander Lewis-Ranwell, now 35, was arrested and released twice before he killed Anthony Payne, 80, and twins Roger and Dick Carter, 84, in Exeter, on 10 February 2019.

Inquests heard concerns about his mental health were raised, but he was released without a Mental Health Act (MHA) assessment that could have led to him being sectioned.

Speaking after the inquests, the Carter family said there had been "systemic failures and missed opportunities that cost them their lives".

In a statement they said they hoped the findings of the inquests would "lead to meaningful, lasting changes across all the organisations involved" with lessons being learned not just in Devon but nationally so that others "are spared the devastating loss we've endured over this time".

"We believe the evidence heard during this inquest demonstrates the need for a national review of guidance and training on mental health issues in police custody so that meaningful lessons are learned and similar failures are not repeated," the statement said.

"Further, private companies such as G4S, who have been outsourced to provide public services, need to be scrutinized much more heavily."

The Payne family added: "We can only hope that the agencies listen to this damning conclusion and take stock of the changes that need to be made to ensure this doesn't happen again to another family."

The inquests had heard evidence of the then 28-year-old Lewis-Ranwell's interactions with various health professionals and police officers during his arrests between 8 and 10 February, which included:

• After his first arrest, on 8 February, Lewis-Ranwell's mother phoned Barnstaple police station saying she would be "extremely concerned should he be released, not just for the violence and the way he was but for his own safety" but he was charged and bailed in the early hours of 9 February
• Following his second arrest for attacking a farmer with a saw later on 9 February, one custody officer described Lewis-Ranwell as "one of the most mentally unwell individuals I can remember encountering"
• Forensic medical examiner Dr Mihail Pichiu - a doctor employed by the now defunct G4S Health Service - deemed Lewis-Ranwell was not "acutely unwell" and did not require a MHA assessment was not carried out

Lewis-Ranwell was released from Barnstaple police station at about 09:30 on 10 February and travelled to Exeter where about three hours later he killed Payne with a hammer at his home on Bonhay Road.

Less than three hours after that he scaled the wall of the Carter brothers' home in Cowick Lane, took a spade from the garden and killed them both with it.

In its conclusions, the jury found shortcomings by police and healthcare professionals employed by Devon County Council, Devon Partnership Trust and G4S probably contributed to the deaths.

The jury said of Devon and Cornwall Police there had been "broad shortcomings in police information gathering, sharing and recording".

Jurors said the failure to record the call from Lewis-Ranwell's mother was a "serious failing that probably made a more than minimal contribution to the deaths".

Other issues with Devon and Cornwall Police included:

• An over-reliance on oral rather than written handovers
• Not looking at details on the Police National Computer
• Not pursuing Lewis-Ranwell's mental health records
• The failure to understand S136 of the MHA, which gives officers emergency powers to detain a person if they appear to have a mental disorder and need immediate care or control
• The failure to detain Lewis-Ranwell on 10 February under S136 of the MHA

Jurors also concluded there were "systemic failures of both Devon County Council and Devon Partnership Trust" relating to the policies and practices around referring detainees for MHA assessments.

The jury also found Pichiu had a "fundamental misunderstanding on how to conduct a mental state examination" and had dismissed signs of delusion and disordered thinking before concluding Lewis-Ranwell did not require a MHA assessment.

They found Pichiu did not meet the requirements for the role of forensic medical examiner and in recruiting him "there was significant evidence of a complete disregard by G4S" of their policies "and thus patient safety".

Lewis-Ranwell, who had a history of paranoid schizophrenia and had been sectioned twice before, was arrested again on 11 February following an incident at an Exeter hotel, the inquests heard.

This time a MHA assessment was completed and he was found to be acutely psychotic.

Lewis-Ranwell was charged with murdering Payne and the Carters but found not guilty by reason of insanity and was given a direct hospital order after a trial later in 2019.

Coroner Philip Spinney said he would be would be considering writing Prevention of Future Deaths (PFD) reports.

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