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A man with mental health issues and a history of making violent threats murdered a woman in a Devon park after falling off a waiting list for a care coordinator, possibly because a health trust’s computer records were compromised by a cyber-attack, an inquest has heard.
If Cameron Davis had been allocated a care coordinator, a multi-agency meeting on him may have been called before he stabbed 74-year-old Lorna England, the senior coroner for Devon, Plymouth and Torbay, Philip Spinney, concluded.
Spinney also highlighted that on the day of the murder, a mental health nurse tried to contact the police on their non-emergency 101 line to report that Davis was threatening to kill someone. The nurse waited on the line for about two hours before he was disconnected.
The inquest heard that Davis had been known to mental health services in Devon from November 2021.
In January 2023, the month before he murdered England, he presented himself at a police station in Exeter and told an officer he would “100%” kill someone. He was taken to hospital but discharged.
On Saturday 18 February, the morning of the killing, he told a paramedic he would kill a “random person” if he was not detained. He was taken back to hospital but again discharged and went on to attack England that afternoon.
The coroner said psychiatric teams had followed the correct procedures in deciding not to detain Davis. But he said: “There was a mistake in 2022 when Mr Davis appeared to be removed from a waiting list. Mr Davis did not have a care coordinator allocated.”
He said: “It is my conclusion that Mr Davis would have greatly benefited from a care coordinator as a single point of contact as would the other agencies involved to share information.
“A care coordinator may have convened a multi-agency meeting after a decline in Mr Davis mental health at the end of January [2023].”
Spinney said a community mental health meeting scheduled for 20 February – two days after the killing – may have been brought forward.
The coroner said a consultant psychiatrist had speculated Davis may have “dropped off the radar” because Devon partnership NHS trust’s computer records system corrupted, preventing access for several months. The psychiatrist said this was caused by a cyber-attack on a company that provided software to the NHS.
The coroner went on to say it was “plain” the 101 service was not working effectively on the day England was murdered. He said the call made by the mental health nurse showed there was a “failure in the system”.
But the coroner said he could not say that if Davis had been allocated a care coordinator or the 101 service had been working better, England’s murder would not have happened.
Hollie Muckley from HCC Solicitors, who has been assisting the family, called for changes in how potentially dangerous individuals are dealt with in the community. Muckley said: “Why hadn’t the police, clinical staff and housing agencies been involved in a multi-agency risk meeting about Davis?”
A Devon and Cornwall police spokesperson said: “We will carefully review and consider each of the findings in detail.” Devon partnership NHS trust declined to comment on the care coordinator issue.
Davis has been jailed for at least 28 years. The coroner concluded England was unlawfully killed.
