A senior barrister believes that coroner-held inquests would have the greatest impact on preventing further murders of people with mental illnesses.
Since 2016, seven homicides in Wales have been committed by patients with severe mental illnesses.
But none of these have been the subject of a thorough coroner's investigation.
According to the Ministry of Justice, it is not possible for it to comment on specific coroners' judgments.
Probably not enough, according to a senior barrister, is the Welsh government's new system for reviewing these cases.
It would take more, according to Lord Alex Carlile, to hold institutions accountable and impart the necessary lessons.
The Welsh government stated that its new reviews would result in "adoption throughout Wales" of the lessons learned from mental health killings.
After being released from a mental health facility 10 days prior, a patient was found in Borth, Ceredigion, by BBC Wales Investigates to have stabbed a stranger.
Despite the fact that doctors emphasized his "worsening mental state" and the risk he "posed with knives," he was released.
Lewis Stone, 71, was attacked by 20-year-old David Fleet as he walked his dog because of "the voices in his head.".
There were "missed opportunities" in David Fleet's care, according to an internal review by the Hywel Dda University Health Board, but the case's lessons were not directly communicated to other health boards or made public.
There was no coroner's inquest or outside investigation into the 2019 murder.
According to Lord Carlile, a former chairman of parliamentary committees on mental health legislation, mandating that there should be a proper inquest in each case of this type would make the biggest single difference in Wales in terms of preventing mental health homicides. .
What do coroner's inquests entail?
- An investigation known as a coroner's inquest is conducted whenever a death seems to have been caused by something violent, unnatural, or unknown.
- Coroners are a special type of judge who answer only to the High Court and are typically lawyers.
- Their inquests are heard in front of the public and may include witnesses and material.
- Typically, they respond to four questions. However, some specialized inquest procedures can also examine whether any organizations may have contributed to the death by making mistakes in the lead-up to it.
- Coroners cannot place blame on specific people, but they can draw a "narrative" conclusion about how the death occurred and recommend steps to help prevent future tragedies in their written reports.
"It's public, so it's accountable, and the evidence is tested forensically," declared Lord Carlile. "By that, I mean the barristers or solicitors can cross-examine witnesses, including expert witnesses, to ensure that everything is revealed.".
He stated that it was crucial to "consider the lessons from prior cases.".
According to several coroners' offices, mental health homicides, which all go through the crown court, are unlikely to also have inquest hearings because doing so runs the risk of repeating evidence already heard.
However, some of the affected families are worried.
In their opinion, more work needs to be done to gather information about potential mistakes and lost chances in the run-up to murders.
Garvey Gayle killed his father in 2020 and stabbed his mother Amanda multiple times four months after being released from a mental health facility.
If her son had received more support, according to Amanda, the attack might have been avoided.
She is still awaiting word on whether Michael's death will be the subject of a coroner's inquest more than two and a half years later.
She worries that lessons, which might aid in preventing similar occurrences, are taking too long.
I just need to know how, perhaps, this could have been avoided if we had more assistance, she said.
"At the moment, there are many questions that remain unanswered that we are still awaiting. ".
Amanda is currently advocating for an Article 2 inquest, a unique kind of inquiry.
This would examine Michael's passing and determine whether any institutions involved in her son's care needed to change.
She claimed that finding out if there was anything that could have been done to stop the attack was crucial for her family.
The new procedure instituted by the Welsh government for these independent reviews is anticipated to last less than a year from the date they are ordered.
One of the first cases under the new system to be examined is that of Garvey Gayle.
Amanda claimed that she had been instructed to wait until the third anniversary of Michael's passing before anticipating the results.
She stated that she was "appalled" at how long it had taken.
I don't think it's at all fair to the family, Amanda continued. "I don't know why these processes have taken so long. I just wish that our situation wouldn't be repeated by another family. ".
The Welsh government, Cardiff and Vale University Health Board, and South Wales Police all stated that they were unable to comment on the case at this time due to an ongoing investigation.
According to the Welsh government, its new review system will acknowledge the need for "greater coordination and communication" between organizations when looking into homicides involving mental health. ".
The need for numerous "onerous and traumatizing reviews" is "eliminated" by the new system, according to a spokesperson.
The statement was followed by the statement that it would "build a greater understanding of what happened during an incident and why, and provide a clear action plan to improve services.
Importantly, it will guarantee that learning is practiced across Wales, they continued.
