Mental health professionals missed "warning signs" before a mentally ill woman bludgeoned a pensioner to death in a Co-op, a review has found. In the unprovoked attack on May 5, 2020, Zara Radcliffe, 30, hit church bell ringer John Rees, 88, with wine bottles and and a fire extinguisher as he lay prone on the floor of the supermarket.
She had walked from her home in Wyndham Street, Tonypandy, to the convenience store in Tylacelyn Road in Penygraig, Rhondda, in the afternoon carrying a kitchen knife. Once there she launched a frenzied attack on multiple people, stabbing them to the head and neck. Mr Rees tried to stop the attack but died as a result of severe blunt force trauma to the face and multiple face fractures.
In March this year, Mr Rees and two other women who courageously tried to stop the attack were awarded the Queen's Gallantry Medal for their bravery. At her trial in October 2020, Radcliffe pleaded guilty to manslaughter of the pensioner by reason of diminished responsibility, and admitted to the attempted murders of three others.
Read more: Digger ends up submerged by the tide on beach at Mumbles
Radcliffe was assessed as being “profoundly mentally ill” with schizophrenia at the time of the offence. She had been hearing voices telling her that people were going to slit her throat and she had stopped taking her medication because of the side effects.
The defendant was sentenced to a hospital order without any time limit. In February 2022 Cwm Taf Morgannwg Safeguarding Board commissioned an independent review of the circumstances which led to the homicide.
The review found that during the hours before the fatal attack, Radcliffe's parents believed she was in a mental health crisis and were "pleading" for help for their daughter from mental health services. "Responses to their phone calls fell short of their expectations. Since [Radcliffe] did not have a Care and Treatment Plan in place, she did not have a crisis plan," the review said.
Radcliffe had been a mental health inpatient ten weeks before the killing. Her involvement with mental health services began in 2016, the report said. She was admitted three times to psychiatric hospitals between February 2019 and February 2020, spending 190 days in hospital during this period.
She suffered with hearing voices and feeling suicidal and was known to misuse drugs and alcohol. She also failed to adhere to her prescribed medication. , Radcliffe lost custody of her child after two violent outbursts involving close relatives and "other events", and later on she spent time in prison.
The report found her parents were "troubled" by many aspects of her care, and that prior to the pandemic "the warning signs concerning [Radcliffe's] rapid deterioration were not recognised or were poorly processed". She had experienced "a number of potentially derailing events" in her early life, including bullying in school and "significant bereavements".
Her parents were "frustrated that mental health services did not engage with the reach of her distressing life events", which they believe began when she discovered her fiancé and father of her child had left her. "[Radcliffe’s] subsequent relationships were violent and [she] increasingly relied on drugs and alcohol," the report said. "Over time, the voices [Radcliffe] could hear became menacing. They threatened her. She reported feeling unsafe on at least 15 occasions during her hospitalisations."
But the report found that when she was discharged from hospital for the final time there was "no planned community support in place for her" and the "onus was on [Radcliffe] and/or her parents to make contact with services". She was last seen by professionals - a social worker and a nurse - when they visited her at home on March 2, 2020, with the pandemic halting routine appointments.
In addition to warning signs being missed, the review found six other areas for learning. One of the areas for learning said there seemed to be "uncertainty" among professionals about Radcliffe's mental health status, with the perception of nurses differing from seven consultant psychiatrists responsible for her hospital care.
The report said "there was no negotiated crisis plan setting out the resources, operating procedures and responsibilities at the point of hospital discharge" and that Radcliffe "did not benefit from the succession of referrals within the hospital and community".
It added that it was not clear that "services were attentive and responsive to [her] decision making over time" and "her decision-making capacity was not questioned". The report also made seven recommendations. "Assessment of inpatients’ mental capacity to consent to their treatment, give instruction concerning information-sharing and related matters, such as leaving the ward, should be undertaken regularly," read one of the recommendations.
Another was that the health board should provide evidence to the Regional Safeguarding Board of "its effective engagement with patients and their families in crisis planning" - including "the preparation of a brief accessible guide" for patients and family, in order "to enhance people’s understanding of likely service responses during mental health crises".
Read next:
- Why Wales' richest man losing £667m could affect us all
- Police officer was sexually inappropriate to woman in pub
- Police issue image after reports of man committing sex act on train
- The richest young people in Wales worth millions
- Alun Wyn Jones finds the perfect words in touching farewell message to Wales
