A man with mental health problems and a history of violent threats murdered a woman in a Devon park after coming off a waiting list for a care coordinator, possibly because a health trust’s computer records were compromised by a cyber attack, an investigation has heard.
If Cameron Davis had been assigned a care coordinator, a multi-agency meeting about him may have been called before he stabbed Lorna England, 74, Devon, Plymouth and Torbay chief coroner Philip Spinney concluded.
Spinney also noted that on the day of the murder, a mental health nurse attempted to contact 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 they disconnected him.
The investigation found that Davis was known to mental health services in Devon from November 2021.
In January 2023, a month before murdering England, he showed up at a police station in Exeter and told an officer he would “100%” kill someone. He was taken to the hospital but released.
On Saturday, February 18, the morning of the murder, he told a paramedic that he would kill a “random person” if he was not stopped. He was taken back to hospital but was discharged again and attacked England that afternoon.
The coroner said psychiatric teams had followed correct procedures in deciding not to detain Davis. But he said: “There was an error in 2022 when Mr. Davis appeared to be removed from a waiting list. Mr. Davis was not assigned a care coordinator.”
He said: “My conclusion is that Mr Davis would have benefited greatly from having a care coordinator as a single point of contact, as would the other agencies involved in sharing information.
“A care coordinator may have convened a multi-agency meeting following a decline in Mr. Davis’ mental health in late January. [2023].”
Spinney said a community mental health meeting scheduled for Feb. 20, two days after the murder, may have been moved up.
The coroner said a consultant psychiatrist had speculated that Davis may have “disappeared” because the Devon Partnership NHS Trust’s computer records system became 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 “clear” the 101 service was not operating effectively on the day England was murdered. He said the call made by the mental health nurse showed there was a “glitch in the system”.
But the coroner said he could not say that if Davis had been assigned a care coordinator or if the 101 service had worked better, England’s murder would not have happened.
Hollie Muckley of HCC Solicitors, who has been helping the family, called for changes to the way potentially dangerous people in the community are treated. Muckley said: “Why weren’t police, clinical staff and housing agencies 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 NHS Trust declined to comment on the care coordinator issue.
Davis has been incarcerated for at least 28 years. The coroner concluded that England was unlawfully murdered.
