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Inquest finds Vittoria Baker was unlawfully killed by her daughter who was mentally unwell

The inquest into the death of Vittoria Baker, aged 52, from Oxford, has concluded that she was unlawfully killed by her daughter K, who was mentally unwell.

Coroners Court

5 July 2019

The Coroner Sonia Hayes sitting at Oxfordshire Coroner’s Court concluded on 20 May 2019 that there had been “systematic failures in communication and clinical leadership that resulted in an unplanned and immediate discharge of her [K’s] mental health section”. The Coroner found that the opinions of nurses who had contact with K were disregarded and an opportunity was lost for a more thorough clinical assessment.
Vittoria herself had been receiving community psychiatric care before she died and had raised significant concerns about the mental health of her daughter. She discussed these serious concerns with a number of professionals, including the police.
On 17 July the police detained K under section 136 of the Mental Health Act following an incident at Vittoria’s home. She was then admitted to Warneford Hospital under section 2 of the Mental Health act on 18 July 2012 but within 24 hours had escaped and travelled to Vittoria’s house. There was a delay in her return and she was not re-admitted until 29 July. She received treatment at Littlemore hospital. 
K had an unplanned mental health assessment on 10 August and nurses raised concerns about psychosis, but these were dismissed and her Mental Health Act section was rescinded on 10 August and she was sent back to Warneford Hospital which she again absconded from and headed to her mother’s house.
She was found there by police on 16 August 2012. Her mother, Vittoria had been fatally stabbed.
MS, the son of Vittoria and brother of K had previously brought a judicial review challenge against a coroner’s earlier decision not to resume the inquest into the death of his mother. The High Court ruled in November 2017 that a coroner had applied the incorrect test in deciding not to resume a suspended inquest and that a full inquest must be held.
MS said:
“I am grateful to the coroner for her investigation of my mother’s death and the failures in my sister’s care. I believe these failures in my sister’s care led to my mother’s death and that more could have been done to prevent this. While my sister was in hospital I tried several times to try to get an update from the medical staff and provide them with valuable information but I was told I was not the next of kin. Her next of kin was designated as my mother, despite the fact that she too was unwell. 
"I should not have had to wait 6 years to hear the truth from the people involved in the care of my mother and sister at the time. Since the death of my mother I believe more lives have been lost and I believe this will continue to happen without true accountability in the decision making process. I hope that lessons can be learned for this case to ensure no other families have to go through what we have been through.”  
Yvonne Kestler, solicitor at law firm Leigh Day said:

“It has now been almost seven years since the death of Vittoria and my client has had to fight to get answers about her death and the circumstances around it, including the care of his sister. I hope the inquest has finally provided some of those answers and that the issues raised will be reflected on by Oxford Health NHS Trust to ensure improvements in communications with families are made.”
Aswini Weereratne QC of Doughty Street Chambers was instructed. 

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