An inquest into the tragic death of a Dearham woman who was killed by her severely mentally ill son heard details of a review which was called for by the crown court judge involved in the trial.

Mary Sowerby, 69, was killed in a brutal attack by her son Lee Sowerby, 45, in her home in Dearham on January 22, 2019.

A week before the killing, Sowerby’s father Leonard sought help at Park Lane Community Mental Health facility, Workington, because he feared something terrible would happen if his son did not receive treatment.

A medication review was arranged for January 21 - but this never took place.

At a trial in Preston Crown Court in July 2019, Sowerby, of Honister Drive, Workington, pleaded guilty to manslaughter on the grounds of diminished responsibility and was handed a life sentence with a minimum term of 11 years.

The Honorary Recorder of Preston Judge Mark Brown said he had serious concerns about the way Sowerby’s case has been handled since the 1990s, and called for an inquiry into Mrs Sowerby’s killing.

He said: “Something needs to be done if only to ensure that lessons are learned and these type of dreadful situations do not happen again.”

Leonard Sowerby and his son, Daniel, were at the inquest held in Cockermouth on Thursday.

Coroner Dr Nicholas Shaw outlined a report commissioned by NHS England and West Cumbria Community Safety Partnership, which was completed last month. It made 17 findings and 28 recommendations.

"There's a lot of recommendations there which will be shared with the relevant bodies. It's to be hoped they take all of these on board," said Dr Shaw.

"The most important one is speaking to each other and families, and taking families' and carers' views on board.

"I think mental health services in West Cumbria have improved since the management was changed to Cumbria, Northumberland,Tyne and Wear NHS Foundation Trust but it remains to be seen.

"Hopefully we do not get any repercussions of this and this will go some way to prevent a future incident.

"Let's hope suitable lessons are learned. The main lesson is to communicate."

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Findings included that an inter-agency information sharing framework (Multi Agency Risk Evaluation) was not utilised following incidents.

It was recommended that the agencies (Cumbria Partnership NHS Foundation Trust, Cumbria Constabulary, Cumbria Probation Trust, Cumbria County Council) should carry out an update and audit.

The report found Sowerby was was not medicated from August 2018. There was no evidence of a care plan following his release from Yewdale Ward, at West Cumberland Hospital, Whitehaven.

"These are pretty damning findings. The common theme is that communications are not good on discharge, between the ward, community team and his family," said Dr Shaw.

"The family were not involved in care planning for Lee despite their requests."

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Sowerby's risk assessment was not updated, found the report. And regarding medical reviews "the system was reactive and not fit for purpose", the inquest heard.

The mental health team was struggling, with high case loads and a lack of medical staff, said the report.

"This was a service in crisis which was not able to deliver," said Dr Shaw.

Recommendations included:

  • The trust must ensure there is a comprehensive admission and discharge policy for Yewdale Ward.
  • The trust must ensure families and carers are appropriately involved in care planning and risk assessment.
  • Cumbria Constabulary must develop a clearly defined process for how concerns regarding a person's mental health can be escalated within the force and between other agencies.

Dr Shaw said: "The horror of this event was not immediately predictable but the feeling was something was going to happen sooner or later with Lee having been lost to follow up by mental health services and the NHS, also no input from GPs.

"They were relying entirely on family care when, in crisis, we know family can only do so much in the face of serious mental health issues which Lee had.

"It's clearly been utterly heartbreaking for you, your family and friends.

"I'm not going to make any further recommendations because they are all here and have gone to the relevant authorities.

"The mental health trust management and organisation has changed and I believe it's improved significantly.

"I also recognise the very difficult work mental health workers do.

"But for him to be lost to follow up at that time was simply not acceptable.

"It's difficult to imagine your feelings Len. You took Lee down there wanting help and there was none forthcoming. You were told to come back in a week when something really needed to be done that day.

"The doctor did not see him and said he would not give medication until he had a review. That review should have been done more urgently."

It was concluded death was the result of multiple stab wounds.

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