A man pinch intelligence wellness issues and a history of making convulsive threats murdered a female successful a Devon parkland aft falling disconnected a waiting database for a attraction coordinator, perchance because a wellness trust’s machine records were compromised by a cyber-attack, an inquest has heard.
If Cameron Davis had been allocated a attraction coordinator, a multi-agency gathering connected him whitethorn person been called before he stabbed 74-year-old Lorna England, nan elder coroner for Devon, Plymouth and Torbay, Philip Spinney, concluded.
Spinney besides highlighted that connected nan time of nan murder, a intelligence wellness caregiver tried to interaction nan constabulary connected their non-emergency 101 statement to study that Davis was threatening to termination someone. The caregiver waited connected nan statement for astir 2 hours earlier he was disconnected.
The inquest heard that Davis had been known to intelligence wellness services successful Devon from November 2021.

In January 2023, nan period earlier he murdered England, he presented himself astatine a constabulary position successful Exeter and told an serviceman he would “100%” termination someone. He was taken to infirmary but discharged.
On Saturday 18 February, nan greeting of nan killing, he told a paramedic he would termination a “random person” if he was not detained. He was taken backmost to infirmary but again discharged and went connected to onslaught England that afternoon.
The coroner said psychiatric teams had followed nan correct procedures successful deciding not to detain Davis. But he said: “There was a correction successful 2022 erstwhile Mr Davis appeared to beryllium removed from a waiting list. Mr Davis did not person a attraction coordinator allocated.”
He said: “It is my conclusion that Mr Davis would person greatly benefited from a attraction coordinator arsenic a azygous constituent of interaction arsenic would nan different agencies progressive to stock information.
“A attraction coordinator whitethorn person convened a multi-agency gathering aft a diminution successful Mr Davis intelligence wellness astatine nan extremity of January [2023].”
Spinney said a organization intelligence wellness gathering scheduled for 20 February – 2 days aft nan sidesplitting – whitethorn person been brought forward.
The coroner said a advisor psychiatrist had speculated Davis whitethorn person “dropped disconnected nan radar” because Devon business NHS trust’s machine records strategy corrupted, preventing entree for respective months. The psychiatrist said this was caused by a cyber-attack connected a institution that provided package to nan NHS.
The coroner went connected to opportunity it was “plain” nan 101 work was not moving efficaciously connected nan time England was murdered. He said nan telephone made by nan intelligence wellness caregiver showed location was a “failure successful nan system”.
But nan coroner said he could not opportunity that if Davis had been allocated a attraction coordinator aliases nan 101 work had been moving better, England’s execution would not person happened.
Hollie Muckley from HCC Solicitors, who has been assisting nan family, called for changes successful really perchance vulnerable individuals are dealt pinch successful nan community. Muckley said: “Why hadn’t nan police, objective unit and lodging agencies been progressive successful a multi-agency consequence gathering astir Davis?”
A Devon and Cornwall constabulary spokesperson said: “We will cautiously reappraisal and see each of nan findings successful detail.” Devon business NHS spot declined to remark connected nan attraction coordinator issue.
Davis has been jailed for astatine slightest 28 years. The coroner concluded England was unlawfully killed.
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