The homicide of a woman by her own son could not have been predicted or prevented, a review by the island’s Safeguarding Board has found, despite the report containing various reports of seemingly missed opportunities.

During one of the lockdowns, the woman was killed by her son while he was suffering from schizophrenia.

At the time of the attack, the man, who has been called ‘Mark’, killed his mother ‘Mrs K’ and seriously assaulted his father ‘Mr K’.

In the weeks leading up to the tragic event, Mrs K and a friend of Mark’s had contacted mental health services on no fewer than five occasions to raise concern about his behaviour, however he didn’t engage with an assessment.

There is plenty of background to this sad tale. However, due to the nature of our island community and it being incredibly likely that people will recognise the people and events involved, we have decided to only provide additional information we felt necessary to explore the recommendations of the Safeguarding Board.

Events

In the weeks before the homicide, a friend of Mark’s phone Manx Care mental health Crisis Resolution and Home Treatment Team, describing him as having a ‘a schizophrenic episode’ and acting ‘paranoid’.

The report says: ‘The friend spoke of Mark’s stress factors from difficult family dynamics. The friend said that Mark had a high level of cannabis use. They did not feel he was an immediate risk to himself or others. Mark was not willing to engage with CRHTT, but the friend agreed to make an appointment for Mark with a GP. The friend was advised they could contact the Emergency Department (ED) or the police if necessary. The case was then closed.’

Two weeks later, Mrs K rang CRHTT, saying she was concerned with his behaviour but no risks were identified to himself or others and Mark was still unwilling to talk with CRHTT. Mrs K agreed to make an appointment with his GP and was given advice about points of contact.

A letter was then unknowingly sent to Mark’s former GP, something which would be repeated at a later date. Both times the GP sent this letter back to be passed onto the correct GP.

The following month, a district nurse (DN) alerted the AST that the relative had returned to live with the family. This was during the Covid Pandemic restrictions. The DN raised a safeguarding adult alert due to further concerns of neglect.

During this time, Mark was repeatedly arrested by the police for breaching isolation requirements before being released home. He didn’t raise any mental health concerns while in custody ‘nor show any concerning behaviours’.

During this period, safeguarding issues were raised around the other relative living in the house, but Mrs K declined offers of support. She did however raise concerns around Mark’s mental health but he wouldn’t engage in the discussion.

When the Adult Safeguarding Team and the district nurse visited the house, they discussed their concerns about the relative staying in the house and the care they were receiving but offers of support were refused.

However, the family did not tell the AST or the district nurse that Mark had assaulted his mother and stamped on her back, this only came to light when Mr K was interviewed after Mrs K’s death.

The Fatal Incident

On the day before Mrs K’s death, Mark had become agitated and hit his mother around the head. This wasn’t reported to the police or the CRHTT.

The relative staying at the house range the police in the early hours saying Mark had assaulted Mr K and when officers attended, Mr K said Mark had tried to strangle him with a towel.

When officers went to rouse Mrs K, they found her to be deceased. Both Mr K and Mark were initially arrested on suspicion of murder, but Mr K was then released.

The report said: ‘Mark was assessed in custody by the Police Forensic Medical Examiner (FME). Mark showed no signs of mental disorder. However, a further mental health assessment by a Consultant Psychiatrist made a preliminary diagnosis of schizophrenia, recommending further assessments to rule out a schizophreniform disorder and a substance induced psychotic disorder.

‘Mark was detained in a secure psychiatric hospital for psychiatric assessment. Mark was subsequently diagnosed as having schizophrenia. The Court accepted the forensic psychiatric assessments that Mark was mentally unwell at the time of the offences. Mark remains in a secure psychiatric hospital.’

Recommendations

Recommendation 1: IOMSB Assurance on Responses to Domestic Abuse

The IOMSB should assure itself that there are robust measures in place for responding to incidents of domestic abuse, including considering the risks and vulnerabilities of all people within the household, particularly children and young people.

Recommendation 2: Developing Responses to Young Carers

Manx Care Social Care should lead an awareness raising campaign about being a young carer. The campaign should target key services for children and young people and provide:

i) Information on the impact of being a young carer

ii) Guidance on the difference that agencies can make to the young carer

iii) Tools and aids to help agencies generate support plans and signpost to support services

Recommendation 3: Assuring Involvement of GPs in Safeguarding and Domestic Abuse

DHSC, working in partnership with Manx Care, should assure there are robust processes in place to correctly identify the adult/child’s registered GP. Assurance should also be sought that GP’s are involved as key multi-agency partners in responses to safeguarding and domestic abuse concerns and that information is shared in line with the permissive provisions of GDPR, IOMSB policies and professional guidance.

Recommendation 4: Building Responses to Domestic Abuse

This review has highlighted that the IOM lacks the basic infra-structure required to respond to Domestic Abuse. This will seriously compromise the safety of IOM citizens experiencing domestic abuse and there is a pressing need to address this.

i) The review recommends this review is shared with the IOM Department of Home Affairs to inform the implementation of its Domestic Abuse strategy.

ii) The review highlighted the following components that should be factored into the IOM Department of Home Affairs implementation planning: