'Treatment resistant' paranoid schizophrenic decapitated neighbour in his front garden after going two months without a visit from medics, inquest hears
A man with 'treatment resistant' schizophrenia decapitated his neighbour in his front garden after going two months without a visit from medics, an inquest has heard.
Kyle Doughty killed housemate Matthew Lynch, 43, before cutting his head off in the garden of their supported housing in Ashwin Road, Handsworth, on July 11, 2023.
Doughty, 33, suffered from 'treatment resistant paranoid schizophrenia' - meaning his condition did not get better with treatment - and was sentenced to an indefinite hospital order last year for the killing.
In the months before his death, the inquest heard, Doughty's mental health declined and that medics last visited his address on May 24, almost two months before he would go on to kill Mr Lynch.
His last contact with a medical professional is believed to have been on June 14, when he spoke briefly with a nurse while appearing 'intoxicated'.
Following the inquest into Mr Lynch's death, senior coroner Louise Hunt warned further deaths could follow and demanded answers for failings from three organisations - Birmingham and Solihull Mental Health NHS Foundation Trust, Provident Housing and Birmingham City Council.
Issuing the prevention of future deaths report, Mrs Hunt said: 'There is a risk future deaths will occur unless action is taken.'
It was recorded Mr Lynch was unlawfully killed and died as a result of 'multiple sharp force injuries' inflicted by Doughty, whom he lived with in shared accommodation.
'Between 5.30am and 5.51am on July 11, Mr Lynch was attacked in the garden area outside the property and decapitated by the offender,' the senior coroner said.
'The offender was known to suffer from treatment-resistant paranoid schizophrenia which would be made worse if he stopped taking his medication and took illicit substances. He had been under the care of mental health services for some time.'
Doughty was last seen at a clinic on May 12, when he told staff he had stopped taking his medication. He agreed to restart it and confirmed he had changed his address.
Further efforts were made to contact him, but he did not respond, prompting concerns his 'mental health condition was relapsing'.
Staff carried out an unannounced visit to an address on May 24 - but he was not present and it was 'not clear if the community psychiatric nurse (CPN) attended his new address or the old address which remained on his clinical records,' the senior coroner said.
He was spoken to briefly by a nurse on June 14 when he 'appeared intoxicated but agreed to attend a clinic appointment on June 21, which he did not attend,' the report said.
Further attempts were made to contact him without success, but no attempts were made to contact his family or the landlord, Mrs Hunt added.
In the days leading up to the attack, Doughty was found using cannabis at the property and was given a verbal warning on June 26.
The day before the killing, Doughty smashed up his room and was evicted from the property.
The coroner said that Doughty had previously behaved similarly and that this was generally a sign of his declining mental health, but added that his landlord did not know this, nor that he was under the care of a Community Mental Health Team.
Despite this, the landlord took him to City Hospital on July 10 as he was 'concerned about his unusual behaviour' - but Doughty left before being seen.
CCTV confirmed he returned to the property before 3am the following morning where he was seen in the garden area having an argument with Mr Lynch. At 5.51am he was captured on CCTV 'striking Mr Lynch with force,' the coroner said.
Mrs Hunt highlighted several 'matters of concern' in the report, including the internal investigation by Birmingham and Solihull Mental Health Trust - which failed to address how, or whether, Doughty's medication should have been monitored after the clinic visit.
'This was important as non-compliance with medication was a risk factor for relapse,' she said.
'In addition, during the inquest the Trust confirmed they had not spoken to the [nurse] who attempted to visit the offender on May 24 to verify whether they had attended the old or new address.
'This was a critical issue as the new address had not been updated on the clinical notes. This raises a concern about the quality of the investigation and whether the Trust is adequately learning from incidents.'
Birmingham and Solihull Mental Health Trust and Birmingham City Council were also questioned regarding mental health assessments as the inquest was told of 'barriers to the use of S2 and S3 Mental Health Act due to Approved Mental Health Professional (AMHP) resistance, administrative challenges and resourcing.'
Mrs Hunt said it 'raises a concern that incorrect Mental Health Act assessments are taking place and patients may be detained on an inappropriate section impacting patient care'.
Information should also be shared between agencies and support worker training, added the senior coroner.
Addressing Birmingham and Solihull Mental Health Trust, Birmingham City Council and Provident Housing, she said landlords were relying on information given by residents, rather than having access to other key information from agencies.
Landlords, therefore, were 'often not aware of key information,' she said
'Given the potential for harm for residents and support workers consideration needs to be given to how best to share information to ensure residents are receiving the right care and landlords have sufficient information to be able to monitor residents and undertake risk assessments,' she added.
Support workers also need more 'focussed training' on mental health conditions and how to manage and help residents with enduring mental health conditions, she concluded.
A spokesperson for BSMHFT said: 'Our thoughts are with the family and friends of the victim in this tragic case. As a Trust we thoroughly investigate all serious incidents in order that the learning from these is applied.
'The Trust will respond comprehensively to the concerns raised by the Coroner in due course.'
