Marta Elena Vento’s killing at Bournemouth Travelodge would have been avoided but for systemic failings by police and prison health provider, says coroner

Marta, from Valencia, was killed in a brutal attack by Stephen Cole, a 32-year-old registered sex offender who had recently been released from HMP Winchester prison, while she was working on reception in the Christchurch Road hotel on 9 December 2020.

Giving a narrative conclusion, the Senior Coroner for Dorset Rachael Griffin criticised Practice Plus Group (PPG), health provider at HMP Winchester, and Dorset Police for failing to follow national guidelines in the discharge of prisoners with serious health issues and the management of offenders who present a risk to the public.

The Coroner said systemic failures by PPG and Dorset Police meant that it was arguable that Article 2 of the ECHR (Marta’s right to life) was breached.

They concluded: “Marta Elena Vento was unlawfully killed by another who at the time of her death was unmedicated for a diagnosed mental health illness because of a failure to sufficiently plan and ensure continuity of his mental health care upon his release from prison six weeks prior to Marta’s death and because he was not adequately managed as a sex offender in line with national guidance upon his release from prison.”

Cole, who had a diagnosis of possible paranoid schizophrenia following a psychotic episode whilst on remand at HMP Winchester, where he attacked two prisoners and two prison officers before he was medicated, was released to no fixed abode on 27 October 2020 with a 28 day supply of anti-psychotic medication Olanzapine but with no care plan to ensure the medication continued.  

He was provided with temporary accommodation at the Russell Court Hotel in Bournemouth by Dorset Council’s housing team. But after his medication ran out, Cole became violent again, attacked two other residents unprovoked and had to be restrained by two security guards. He was arrested by Dorset Police and evicted from the hotel. After being released on bail, Cole’s family booked him into the Travelodge and tried to get him medication. However, this did not happen, he suffered another psychotic episode and just after 5am on 9 December 2020 brutally killed Marta who was working a nightshift alone on reception.  

Cole pleaded guilty to manslaughter by reason of diminished responsibility and was sentenced at Winchester Crown Court on 1 June 2021 to be detained indefinitely in a secure hospital.  

The Coroner heard that Cole had not slept for several days and had run out of his medication on 24 November, two weeks before the attack happened. An appointment with his registered GP on 8 December, and previous contact with out-of-hours GPs and paramedics on 5 and 6 December, had failed to secure a prescription for more Olanzapine. Cole’s offender manager in Dorset Police, who was responsible for managing him in the community, had not contacted his GP or mental health services with concerns about Cole not having medication.

It was a failure of continuity of care that Cole’s GP and community mental health team were not told by PPG that he had a confirmed diagnosis of psychosis following a psychotic episode while in prison, that he had a potential diagnosis of  schizophrenia, and was prescribed anti-psychotic medication which he needed to keep taking, the Coroner agreed.

The court heard evidence that PPG had lost 67 per cent of its staff when it had recently taken over as health provider at the prison. The staff who remained did not have time to carry out administrative tasks, the court heard.

The Coroner agreed with Marta’s family lawyers that systemic failings by PPG (lack of staffing and lack of training) amounted to an arguable breach of the Article 2 duty to have in place systems and practices to protect the lives of citizens.

The Coroner concluded that PPG had no integrated mental health policy in place between July and October 2020 and there was no effective system in place at HMP Winchester for comprehensive care planning.

There was no release planning in place for Cole. He was not discharged to his GP or referred to the community mental health team who could have supported the GP with appropriate medication guidance.

The Coroner criticised Dorset Police who were responsible for managing Cole’s risk to the community after his release from prison under Multi Agency Public Protection Arrangements (MAPPA).

The Coroner found that Dorset Police’s failure to manage Cole’s risk to the public was an arguable breach of the Article 2 systems duty because of deficiencies in its Managing Sexual Offenders and Violent Offenders (MOSOVO) unit, which was not operating in line with national guidance.

Dorset Police failed to gather essential information to identify the risk he posed. They did not contact Cole’s GP or consult the police national database which would have secured information that would have meant Cole would have been managed as a MAPPA level 2 offender. They also did not contact the prison to request information about his behaviour during his imprisonment.

The coroner concluded that Marta’s death would have been avoided but for systemic failures by PPG and Dorset Police in the management of Cole.

Evidence was given to the inquest by: the Ministry of Justice; Practice Plus Group; the Chief Constable of Dorset Police, the Chief Constable of Hampshire Police; Dorset Healthcare University NHS Foundation Trust; University Hospitals Dorset NHS Foundation Trust; South West Ambulance Service NHS Foundation Trust; Dorset Council; Orchid House Surgery and Travelodge. 

The coroner said they will make prevention of future deaths recommendations to: 

• HM Prison and Probation Service in respect of the lack of national guidance around sharing information with sentencing courts which may impact on the risk of harm or reoffending when a person is remanded in custody awaiting sentencing 
• NHS England in respect of the lack of national guidance on how to ensure the continuity of care when a prisoner with healthcare needs is released from prison homeless and with no registered GP 
• The College of Policing in respect of the lack of guidance on how to risk assess and manage offenders who are managed under MOSOVO who present with a risk of violence 
• The National Police Chiefs’ Council in respect of the lack of a national assessment tool for MOSOVO representatives to use to assess the risk of violence posed by offenders 
• NHS Dorset in respect of the lack of implementation of the National Record Locater in Dorset 

When the fatal attack happened, Marta had been working at Bournemouth Travelodge for just under three months.

Marta, from Valencia, had moved to the UK in 2015 and until 2017 worked at a hotel in Scotland. After returning to Spain to complete her studies, she worked in Preston in 2019 and then moved to Bournemouth in 2020.

When the pandemic happened, Marta moved back to Spain, but was keen to return to the UK and was able to do so later that year. She was living with friends and had been glad to find a new job at the Travelodge.

Her family heard the six-week inquest from home in Valencia, listening to evidence through an interpreter.

In a pen portrait they described her as a quiet sensitive girl and said without her their lives were shadows of what they were, “with no happiness or hope”. Their only consolation was to “stay united” and “try to preserve the wreckage of what was once a happy family”.

The family are represented by Benjamin Burrows and Ellie Sutherland at law firm Leigh Day.

Counsel for the family is Matthew Hill of 1 Crown Office Row.

Following the conclusion Benjamin Burrows read out a statement on behalf of Marta’s family. 

Family statement:

“Today’s conclusion confirms what we have suspected in the four long years since our dear Marta was torn from our lives.

“It is overwhelmingly hard for us to understand how the English prison health system could allow someone like Stephen Cole, who was so clearly unwell, to be released without a care plan and the ongoing medication he needed. It is equally hard for us to understand why the English police did not make themselves fully aware of the danger Cole posed when he stayed at the Travelodge on that night.

“Our daughter paid with her life for lapses in the English prison and policing systems. The cost to our family can never be measured. Without our Marta, our lives will never be the same.”

Leigh Day partner Benjamin Burrows said:

“We welcome the Coroner’s findings, which very much reflect the concerns that Marta’s family have held in the four years since her death.

“The clear conclusion is that Marta’s death aged just 27 would have been avoided.

“If Practice Plus Group had provided continuity of care to Stephen Cole on his release from HMP Winchester it would have probably meant that he stayed on his medication and he would not have relapsed into psychosis.  

“The same would have happened if Dorset Police had properly assessed and managed Cole’s risk.

“Either of those steps would have prevented Cole killing Marta. This is very difficult for the family to come to terms with, but finally gives them the answers they have been waiting for.

“Marta’s family have shown enormous dignity and courage through these proceedings and it has been a privilege to represent them and help them fight for the answers they have finally received today.

“However, here is yet another example of the State failing in its duty to protect the public. Marta’s case has laid bare systemic failures in our prison and policing systems. It is not enough to say that lessons will be learned, clear action needs to be taken. Marta’s family will be watching to see that this time something is done to stop such tragedies happening again in the future.”