Lack of joined up work by Oxford Health could have led to death of Justin Skrebowski

A CORONER has concluded that a string of failures by a health authority could have contributed to a fatal attack on a father-of-two.

The inquest for 61-year-old Justin Skrebowski concluded at Oxford Coroner’s Court today, more than two years after the Oxford art dealer was stabbed to death in Abingdon’s Poundland.

Oxfordshire Coroner Darren Salter highlighted ‘lost opportunities’ for Oxford Health NHS Foundation Trust to better protect the public from Mr Skrebowski's killer, Trevor Joyce, who randomly lunged at his victim with a carving knife on December 7, 2015. 

Throughout the five-day inquest, the coroner heard a catalogue of evidence from healthcare workers and police who dealt with schizophrenic drug dealer Joyce.

A key theme was lack of communication between authorities.

Recording a narrative conclusion, Mr Salter said: “The death was possibly contributed to by failures on the part of the health trust to having a documented and comprehensive care plan, and also inadequate senior management and senior medical review of his overall risk to the public.”

Oxford Health provides healthcare in the county, and Joyce’s community care team came under fire for a series of oversights.

The trust’s own policy states patients such as Joyce must have a ‘care plan’: a written document reviewed at least every six months, which details care needs and should be compiled with help of other parties such as police. 

There was no such document for Joyce until November 26, when a brief version was hurriedly put together by his care worker upon request of a housing agency.

Several healthcare workers questioned during the inquest also admitted Joyce should also have had a ‘care programme approach (CPA) review’, which is a meeting in which key agencies meet to map out how best to manage a patient in the community.

Mr Salter told the court today: “Even without the benefit of hindsight, it seems clear there should have been a comprehensive care plan and CPA review.”

He noted the trust made little effort to include charity Turning Point in Joyce’s care, despite him working with the charity to overcome drug and alcohol abuse.

Mr Salter said: “That’s surprising, given the pivotal role they might have been expected to play.

“There was a clear causal link between drugs, his mental health and risk to the public.”

He also refreshed the inquest on evidence given last week by specialist doctor Toby O’Hanlon. 

Joyce went to Poundland and cut himself with a knife days before he killed, telling Dr O’Hanlon he wanted to stab customers.

Dr O’Hanlon failed to tell police, and admitted to the court that he had ‘not had time’ to read Joyce’s case notes, meaning he was unaware of details such as that he had a history of making threats to kill. 

Sean Horstead, representing Mr Skrebowski’s family, said: “That’s simply not good enough.

“These are essential pillars of an appropriate and fit for purpose review system.”

Mr Salter also noted how Joyce was discharged from Littlemore Mental Health Centre six weeks before he killed, against the advice of his community care team.

He said there was a ‘lost opportunity for a coordinated approach’ at Joyce’s discharge, as there was no meeting between the inpatient and community teams. 

Joyce had been ‘distressed’ in the run-up to the stabbing after learning two of his three key care workers were leaving, the court heard.

He had had five different care coordinators and the most recent was due to leave that December, at the same time as a trainee doctor. 

During the inquest last week, Mr Horstead said: “That little team was coming apart. Two of three legs of the tripod that had been established were disappearing. 

“He felt isolated and unsupported.”

Mr Salter agreed this high staff turnover and lack of continuity of care had an ‘adverse’ effect.

The inquest has concluded and the coroner will write to authorities to recommend if anything can be done to prevent future deaths.

A spokesman for Oxford Health said: "We would like to offer our most sincere condolences to Mr Skrebowski’s family at a very difficult time for them.

"We always strive to do everything we can to ensure we provide the highest possible standards of care at Oxford Health, but there were actions that could have been better performed in this case, and for those we are sorry.

"Following Mr Skrebowski’s tragic death, the trust has undertaken a review of our services and implemented a number of changes based on our own review.

"We are also awaiting the findings of an independently commissioned report by NHS England, which we hope will provide further assurances to both Mr Skrebowski’s family and the wider community we serve.

"The Trust will now carefully consider all of the evidence heard at the inquest, along with the findings of NHS England review, to ensure any necessary changes which have not already been made are fully addressed."

THE family of Justin Skrebowski had previously pointed the finger at police as well as the health trust, for failing to protect the public from Joyce.

During the inquest the court heard Joyce, who is serving life for manslaughter, was arrested for a catalogue of crimes in 2015 and had been known to police since 1997. 

Concerns were addressed during the inquest about the fact Joyce was on conditional bail at the time of the stabbing, and why magistrates granted him this when he was committing an increasing number of offences.

These included public order offences, criminal damage, indecent exposure and harassment.

But Chief Crown Prosecutor Adrian Foster told the inquest magistrates had no power to remand him in custody rather than grant bail, and they acted ‘perfectly properly’. 

Joyce had also admitted to his healthcare workers in October that he had threatened to kill his neighbours, which police were still investigating at the time of the stabbing.

In 2013 he was also arrested for threatening to kill his neighbours, but police took no further action after deciding it was ‘not in the public interest’ to charge him for the offence.

Yesterday Mr Salter concluded there were ‘no causal failings identified on the part of Thames Valley Police’, and Mr Skrebowski’s family’s lawyer told the court they accepted this.