Devastated loved ones of a father-of-two who was stabbed to death in a Poundland store have slammed health services and say his was death ‘predictable and preventable’.
Justin Skrebowski had gone to the store to buy balloons for his wife’s birthday when he was attacked and killed by schizophrenic Trevor Joyce.
Coroner Darren Salter yesterday concluded that failures of the Oxford Health NHS Foundation Trust could have contributed to 61-year-old Justin Skrebowski’s death on December 7 2015.
Trevor Joyce stabbed father-of-two Just Skrebowski to death in a Poundland in December 2015
He could be seen rampaging down the street after the stabbing, holding the same knife he had used to kill Mr Grabowski
A statement released by Mr Skrebowski’s family said: ‘The last two years have been an unimaginably traumatic period.
‘We are grateful that the many failures and inadequacies in the care of Mr Joyce have been identified.
‘The failure of senior clinicians and management to properly manage Mr Joyce’s care and the obvious risk that he presented to the public has been shocking.
‘We remain of the view that his death was both predictable and preventable.
‘The sheer number of failings identified by the coroner to have possibly contributed to this unnecessary death speak for themselves.’
Coroner Darren Salter yesterday concluded that failures of the Oxford Health NHS Foundation Trust could have contributed to 61-year-old Justin Skrebowski’s death on December 7 2015
Mr Skrebowski’s family pointed to ‘complacency’ of senior healthcare staff and managers, stressing how Joyce was ‘known to be a serious risk to the public’.
A catalogue of concerns were raised about Joyce’s care, including a lack of communication between health practitioners to act on concerns about Joyce, who repeatedly warned doctors he wanted to stab someone.
The trust’s own policy states patients such as Joyce must have a ‘care plan’: a written document reviewed at least every six months, which details care needs and should be compiled with help of other parties such as police.
There was no such document for Joyce until November 26, when a brief version was hurriedly put together by his care worker upon request of a housing agency.
In a statement the heartbroken family said: ‘The failure of senior clinicians and management to properly manage Mr Joyce’s care and the obvious risk that he presented to the public has been shocking’ (pictured: Joyce after the stabbing)
At an inquest, a catalogue of concerns were raised about Joyce’s care, including a lack of communication between health practitioners to act on concerns about Joyce, who repeatedly warned doctors he wanted to stab someone
Several healthcare workers questioned during the inquest also admitted Joyce should also have had a ‘care programme approach (CPA) review’, which is a meeting in which key agencies meet to map out how best to manage a patient in the community.
Mr Salter told the inquest: ‘Even without the benefit of hindsight, it seems clear there should have been a comprehensive care plan and CPA review.’
He noted the trust made little effort to include charity Turning Point in Joyce’s care, despite him working with the charity to overcome drug and alcohol abuse.
Mr Salter said: ‘That’s surprising, given the pivotal role they might have been expected to play.
‘There was a clear causal link between drugs, his mental health and risk to the public.’
Several healthcare workers questioned during the inquest also admitted Joyce should also have had a ‘care programme approach (CPA) review’, which is a meeting in which key agencies meet to map out how best to manage a patient in the community (pictured: The Poundland where the stabbing took place)
The inquest was refreshed on evidence given by specialist doctor Toby O’Hanlon.
Joyce went to Poundland and cut himself with a knife days before he killed, telling Dr O’Hanlon he wanted to stab customers.
Dr O’Hanlon failed to tell police, and admitted to the inquest that he had ‘not had time’ to read Joyce’s case notes, meaning he was unaware of details such as that he had a history of making threats to kill.
Sean Horstead, representing Mr Skrebowski’s family, said: ‘That’s simply not good enough.
‘These are essential pillars of an appropriate and fit for purpose review system.’
Coroner Salter also noted how Joyce was discharged from Littlemore Mental Health Centre six weeks before he killed, against the advice of his community care team.
Joyce went to Poundland and cut himself with a knife days before he killed, telling Dr O’Hanlon he wanted to stab customers
Joyce had been ‘distressed’ in the run-up to the stabbing after learning two of his three key care workers were leaving, the inquest heard.
The attack left Mr Skrebowski’s twins, Rosy and Enes, now five-years-old, without a father.
His widow Gulsa Alkan, 41, said: ‘On the day I used to celebrate my birthday, Justin lost his life at the hands of someone for whom greater care should have been provided.
‘If it hadn’t been Justin, it would have been someone else.
‘Justin paid with his life and we will bear the loss of these failures.
‘We would all like to extend our condolences to the many people who have lost loved ones in similar circumstances since the death of Justin.’
Recording a narrative conclusion, Mr Salter said: ‘The death was possibly contributed to by failures on the part of the health trust to having a documented and comprehensive care plan, and also inadequate senior management and senior medical review of his overall risk to the public.’
Joyce being pinned down after he killed Justin Skrebowski in a stabbing in a Poundland
Oxford Health spokesman Chris Kearney extended condolences to the family.
He said: ‘We always strive to do everything we can to ensure we provide the highest possible standards of care at Oxford Health.
‘There were actions that could have been better performed in this case, and for those we are sorry.
‘Following Mr Skrebowski’s tragic death, the trust has undertaken a review of our services and implemented a number of changes based on our own review.
‘We are also awaiting the findings of an independently-commissioned report by NHS England, which we hope will provide further assurances to both Mr Skrebowski’s family and the wider community.
‘The trust will now carefully consider all of the evidence heard at the inquest, along with the findings of NHS England review, to ensure any necessary changes which 1have not already been made are fully addressed.’
Parts of the NHS England report were read at the inquest yesterday, and admitted some failures but concluding: ‘We cannot say the tragic death of Mr Skrebowski was preventable’.
In 2016, Joyce was jailed for life after pleading guilty to manslaughter on grounds of diminished responsibility.