Patient killed by teen after staff failures, jury finds

A man was strangled to death by a fellow patient on a psychiatric ward following failures by health staff, an inquest jury has found.

Owen Herbert, then aged 18, attacked 63-year-old Richard Laversuch in the early hours of 27 November 2021 at Parklands Hospital, in Basingstoke, Hampshire.

In a narrative conclusion, the jury in Winchester said Laversuch, from Andover, was unlawfully killed after Herbert was incorrectly admitted to a less secure ward. Hampshire coroner Nicholas Walker said: "Poor decisions were made one after the other."

In a statement, Hampshire and Isle of Wight Healthcare NHS Foundation Trust said: "Richard should have been safe on our ward and we failed him."

Herbert was detained under the Mental Health Act in November 2021 because he had been hearing voices and had left his home in Overton, Hampshire, with weapons, the court heard.

He believed he was "in a game" and would be "tortured" if he did not kill someone, the jury was told.

Minutes before killing Laversuch, he tried to strangle another patient.

However, when staff investigated that patient's report, they found Herbert in bed and "doubted the account of the attack", the jury concluded.

The jury said an approved mental health professional (AMHP) from Hampshire County Council incorrectly named a lower-risk ward when Herbert was admitted to the hospital.

When the teenager arrived, no Psychiatric Intensive Care Unit (PICU) bed for higher-risk patients was available, jurors found.

Staff admitted Herbert to the lower-risk ward despite previously being told it was unsuitable for him.

"Nursing staff placed an over-reliance on the calm presentation of the patient," the jury concluded.

Previously, the trust told the inquest it accepted five failures.

Herbert should have been admitted to a PICU, higher-risk ward, in accordance with national standards, the trust acknowledged.

It said there was also a failure by staff to carry out a risk assessment when he was admitted, the ward was insufficiently staffed, his patient record prior to admission was not properly written up and there were communication failures over his admission.

The coroner said: "I cannot imagine how hard it would have been for Richard's siblings to learn how easily his death could have been avoided."

He added he would be writing a Prevention of Future Deaths Report on admissions procedures and risk assessing patients.

Herbert, who previously pleaded guilty to manslaughter, was given an indefinite hospital order in 2023 and is detained at Broadmoor Hospital.

Following the inquest, the NHS trust apologised to the men's families and said it had made many changes as a result of the death.

Chief executive Ron Shields said: "I am profoundly sorry for the gaps in our care.

"We have strengthened communication and decision-making around access to the right beds, increased senior nursing presence on the wards day and night, and strengthened clinicians' ability to assess risks and escalate concerns."

Hampshire County Council and the Department of Health and Social Care have also been approached for comment.