Inquest concludes that Vera Croghan who died in a fire started by her grandson was unlawfully killed

During the inquest, the family raised repeated concerns over the mental health care provided to Marco by Norfolk and Suffolk NHS Foundation Trust and Southern Hill Hospital and the handling of the incident involving Marco by Norfolk Constabulary. The family also raised concerns about the social care provided to Vera by Norfolk County Council which they argued should have been included in the scope of the inquest. The family had been concerned about the care provided to Vera and complained to Adult Social Care 18 months before her death.  The Adult Social Care team would not consider their concerns unless Vera herself made a complaint due to policy. The family were later informed that this policy did not exist.

The Adult Social Care team at Norfolk County Council have since accepted that following the family raising concerns about Vera in June 2019 they should have visited Vera. The coroner did not agree that the concerns and the involvement of the Adult Social Care team should be considered within the Inquest.

The family were also disappointed by the coroner’s decision not to obtain Marco’s mental health records. The reason for refusal was due to Marco’s privacy. However, the family consider it was crucial to do so as a matter of public interest in relation to the actual care and treatment provided to Marco, the existence of potentially dangerous persons in the community with psychotic behaviours and the responsibilities of mental health providers to protect others from the risks presented by Marco.

Vera’s inquest heard that on 31 May 2020 Marco was removed by police from Vera’s property and on 1 June 2020 he was admitted under section to Southern Hill Hospital.  During a Mental Health Act assessment on 1 June 2020 when he was assessed as a high risk to others, mental health professionals were informed that Marco had a phobia about his grandmother not liking him and she was anxious and scared of him. It was reported to mental health professionals that Marco had moved from Thailand following a violent attack on his mother.

No safeguarding alerts were raised and this information did not factor into the subsequent discharge planning or risk assessments.

Marco was discharged on 18 June with his risk to others reduced to low with a factor being that whilst hospitalised Marco was compliant with medication.

He was transferred to the Community Early Intervention Team. It became known to the Early Intervention Team that Marco was living with his grandmother. Marco reported his concerns about his grandmother’s care needs and he considered she was suffering from dementia. Again, no enquiries were made concerning Vera’s wishes or to assess the potential risk to Vera if Marco stopped taking his medication and again took illicit substances.

When Marco moved to Manchester for a university course in September 2020 he was discharged from mental health services in Norwich but did not give consent for his medical history to be discussed with the mental health services in Manchester.

His Norwich referral was kept open and he told NSFT Early Intervention Team during telephone calls that he was no longer taking his medication, which had been a factor in reducing Marco’s risk.

Marco’s father made numerous contacts with the NSFT Early Intervention Team including on 10 December, but the appointment for Marco was not until six days later.  Marco’s father was advised that if Marco became violent he should call 999. He was not given the number for the 24/7 Crisis Team at this time.

Marco’s father gave evidence that on the evening of 10 December he was frightened and concerned about Marco’s behaviour. He had recognised that Marco’s behaviour was similar to how he presented prior to the earlier episode in May 2020, and he was fearful that Marco would become violent again. Two police officers attended at Vera’s address, one who had been present during the earlier incident in May 2020. They were followed by a sergeant who had also been present in the May 2020 incident. Vera’s family do not consider that the police carried out a proactive and comprehensive risk assessment. The police were aware of Marco’s previous mental health problems prior to attending the property. The police officers accepted in evidence that they dealt with the call out as a response to a violent act rather than a response to a breakdown in Marco’s mental health.  Marco was not asked any questions to assess his mental health, for example whether he had been taking his medication, use of illicit substances or changes in behaviour. The family do not consider that there was any attempt by the police to determine whether Marco’s mental health was affecting his behaviour towards his father.  Marco was asked closed questions and when he did not answer the police failed to consider whether this revealed any alteration to his mental state.  It is the family’s view that further action should have been taken by the police to remove Marco or alternatively remain in the property until the mental health Crisis Team had been contacted.

Marco’s father was extremely anxious and expressed his fear that as soon as the police left that Marco would ‘start again’ and commented ‘I just hope I am alive by the morning.’ Marco’s father was advised to close his bedroom door and place items behind the door.  After the police left the property Marco’s father decided leave the property.  In the early hours of that morning Marco set a fire in the cupboard underneath the stairs which became a smouldering fire.  Vera sadly died of inhalation of fire fumes.

The family asked the coroner to use her powers to write a Prevention of Future Deaths report to the relevant authorities as they continue to have very serious concerns that lessons have not been learnt following Vera’s death. Unfortunately, the coroner did not make a Prevention of Future Deaths report.

Following the conclusion of the inquest into Vera Croghan’s death, her daughter Karin Ronen said:

“We believe our mum was failed by Norfolk’s care, mental health and police services before her homicide; and failed by the criminal and coronial systems after her death. We feel there has been no justice, and so many questions remain, in our opinion, deliberately unanswered. After waiting almost four years, we feel we have still not received the answers we deserve.

“From the evidence heard at this inquest, it is clear to us there was no joined up working between the various authorities who dealt with our mum. As a result, there was no wider awareness of her situation or who should take responsibility in a crisis. We believe there were multiple opportunities across the Adult Safeguarding Team, Mental Health Services and the police to identify risk, all of which were either ignored, dismissed or dealt with in isolation.

“Mum’s case is an example of a systemic failure to reflect and learn from mistakes made. We are deeply disappointed that the coroner has not highlighted this within the conclusion. What is needed is joined up thinking to prevent such tragedies, but this will never happen unless there is true accountability when things go wrong.

“To sit through an inquest where most of those involved have failed to express any form of compassion, concern, regret or even reflection has been extremely difficult and harrowing. As a family we deserved answers, not excuses. However, by restricting the scope of this process and refusing to call relevant witnesses, we feel our last chance to get to the truth - and ensure that real and effective learning takes place - has been denied us.

“Mum was an elderly and gentle lady who had many vulnerabilities in her later years. She had contributed to society her whole life and instilled in us a keen sense of independence and an understanding of right and wrong. She deserved dignity in death. Instead, this final attempt to get some answers following the horrific death of our much-loved mum has left us all feeling disappointed and frustrated with the system.

Vera’s son Mike Croghan said:

“Our mother’s death was foreseeable and avoidable. This process and the conclusion has papered over the cracks in the institutions that are meant to protect and serve the public. A golden opportunity to make recommendations to help prevent future deaths has been missed. The mental health services, the police and adult social care all failed to adequately assess risk, failed to communicate and failed to take the pleas for help seriously. Our mother was isolated, ignored and invisible.

“Our mother, Vera Croghan, awoke in the early hours of the 11 of December 2020. Her face and hands were badly burnt so we think she had tried to open the door and had been blown back.  We believe she lay on the floor unable to move, waiting to die. Eventually, she succumbed to the smoke from the fire. No one should die like that.

“When will the services that are meant to protect the public ever learn to look at the whole picture?"

Vera’s son James Croghan said:

“The thwarting of learnings out of this process leaves us deeply concerned about future lives being lost, particularly amongst the vulnerable and the invisible elderly. Those who fail to learn from the past are destined to make the same mistakes in the future.”

Karin Ronen, Mike and James Croghan were represented by Leanne Devine, partner at Leigh Day and Emma King, Barrister at One Pump Court Chambers, both members of Inquest Lawyers Group.

Leigh Day partner Leanne Devine, said:

“It has become apparent through the evidence presented at this inquest that there was a clear lack of multi-agency co-ordination to protect an elderly and vulnerable member of the community.  It was known that Vera’s grandson presented a risk, he had a history of violence and he was non-compliant with medication. There was a lack of professional curiosity concerning Vera’s wishes, her wellbeing and her safety.

“This is another family who have had to push for evidence to be disclosed, witness statements to be obtained and an opportunity to ask questions about the death of their loved one.  During this Inquest Vera’s family have relived the trauma of losing their mother but have had to endure another process which has failed to identify key learnings which could help others in the future.”

Julian Hendy from the Hundred families charity which supports families after mental health related killings said:

“We are concerned about the quality of care for seriously unwell people who need urgent, assertive, mental health care and treatment in Norfolk. We have documented 40 homicides by patients of the trust in the last 20 years. We believe many of them could have been prevented.

“We are aware of enduring concerns about safety at the trust and calls for a public inquiry. According to the Care Quality Commission the Trust ’requires improvement’.

“Too many families are being failed. The Trust does need to show they are listening and acting urgently to prevent further avoidable tragedies.”