Mental health trust reviews risk assessment after discharged man stabbed dad to death

CHANGES have taken place since the fatal stabbing of a Kingsteignton man by his son who was inadequately risk-assessed before being discharged from mental health services, an inquest heard.

A two-day hearing was told that 73-year-old Peter Freeman was stabbed multiple times with a Bowie knife – a fixed-blade fighting knife – on his doorstep.

The attacker was his son, Owen Chandler, 42, who was found dead in his car the following day, June 10, 2019.

Chandler had a long history of mental health illness and had repeatedly told therapists over the years that he had wanted to kill his parents and himself.

However, his risk to himself and family members was said to have not been properly assessed by professionals, which resulted in him being discharged from all mental health services seven months before the murder.

Retired senior coroner Ian Arrow, appointed by the chief coroner to conduct the inquest, recorded a conclusion of unlawful killing.

He said: “His assailant had previously been under the care of mental health services with a diagnosis of emotionally unstable personality disorder.

“The assailant had been discharged from that mental health service in November 2018. At the time of discharge from mental health services there had been limited assessment of the risk he posed to others.”

Adult mental health services provider Devon Partnership Trust (DPT) carried out its own root cause analysis (RCA) following Mr Freeman’s death. It concluded that no recommendations for change were required.

However, an independent niche report gave nine recommendations to improve care and prevent any future serious incidents. A trust representative told how it has resulted in “large scale” changes taking place, in particular to risk assessments and greater integration between its different services.

An update on the trust’s action plan and outstanding matters is due to be completed by the end of May. Mr Arrow requested that the trust write to him and the Freeman family by June 14 to confirm the stage the trust is at for him to then decide on June 17 whether to use his powers to issue a Prevention of Future Deaths Report.

Mr Freeman’s wife Linda told police that she and her husband had been at their bungalow in Chockland Road watching television when their doorbell rang at 9.15pm on June 9, 2019.

She told how Mr Freeman, a retied window fitter, answered the door and did not recognise the visitor who had been wearing a hoodie.

He was said to have asked whether the “Johnson family” lived there or at a nearby address and was told they did not.

Chandler was then said to have attacked Mr Freeman with a knife leaving him unconscious in the porch. Mrs Freeman was able to lock the front door and called 999 at 9.20pm while Chandler tried to gain access into the home.

Doorbell footage at their home showed he “hurredly” left the scene at 9.20pm. Mr Freeman was pronounced dead shortly afterwards at Torbay Hospital.

The cause of his death was stab wounds to the neck and chest. Chandler was found the next morning, after a member of the public telephoned police to report finding a man dead in a vehicle at Labrador Bay. Inside the car, the police found the blood-stained murder weapon and a letter in the glove box addressed to the coroner in which parts of it referred to the incident the previous day.

It was then Mrs Freeman discovered the identity of her husband’s killer.

The inquest, held at Plymouth Coroners Court last week heard

Chandler had suffered with his mental health since he was a teenager and had been diagnosed with emotionally unstable personality disorder and post-traumatic stress disorder, and had a history of self-harming.

He was discharged from psychological therapy in August 2018 and then by the Community Mental Health Team (CMHT) in November 2018. His patient records from 2011 and 2012 were said to have contained details of him having urges to kill animals and his parents, and admitting to having twice driven past his parent’s house late at night with thoughts of revenge and killing impulsively and that if he did he would “stab them”.

In May 2012, he said if he decided to kill himself he would kill his parents first as he “had nothing to lose”.

Dr Anna Laws, a consultant clinical psychologist, who carried out an independent investigation into the care Chandler had received from DPT said: “Mr Chandler, during his period of care under DPT, changed the way he thought about his father and the clinical psychologist caring for him did not recognise the potential of increased risk of Mr Chandler to himself and to his father.”

⟫Peter Freeman