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28 May 2013, 18:19 | Updated: 30 March 2016, 13:50
A report's found a mental health worker, stabbed to death by a paranoid schizophrenic in the North East, shouldn't have visited him alone.
Ronald Dixon stabbed 22 year old Ashleigh Ewing, 39 times, breaking three knives in the process, when she went to his home to deliver a letter from her employers.
An investigation into the circumstances surrounding her death has criticised health chiefs from Northumberland, Tyne and Wear NHS Foundation Trust and said that Dixon should not have been managed in the community.
Dixon, described in the report as a loner, had a history of mental illness and had previously attacked his parents with a hammer while they were in bed.
The report, commissioned by the North East Strategic Health Authority, outlines how by 2006 when the stabbing took place, he was in relapse and had disengaged from services.
But in spite of this, on May 19th, 2006, psychology graduate Ms Ewing, who worked for housing support charity Mental Health Matters, was sent by herself to his home with a letter telling him he was in debt.
Within 15 minutes of her walking through the door a neighbour heard screams and shouts of "get off' and ''stop it".
A minute-long "hysterical screech'' was then heard, before Dixon changed his bloodied clothes, showered and with his dogs walked to a police station and said he had murdered someone.
The report said:
"It is the view of the panel that if a robust risk assessment had been completed including a consideration of the lone working policy with P [Dixon], such lone working would have been abandoned and joint visits implemented.
Thus, it must follow, that A [Ewing] would not have been attending P's [Dixon's] house on her own on 19 May 2006.''
It describes the letter she had with her as "provocative'' and said that it was "entirely inappropriate'' for her to have delivered it to him.
It also says there was "a misplaced but substantial over-reliance upon Mental Health Matters' staff'' by clinicians from the Trust.
"The reliance on Mental Health Matters staff to report on P [Dixon] led to a situation where P's mental state was never properly established or assessed on a regular basis.
It was, in our view, wholly inappropriate to rely upon Mental Health Matters as the conduit for reporting on P's [Dixon's] mental state and clinical signs.''
While the panel found that "it is impossible to conclude with absolute certainty that the vicious attack could have been predicted or avoided'', they do say he should have previously been detained under the Mental Health Act.
They also conclude that throughout the period in question a "light approach'' had been taken towards Dixon's care, but his condition "demanded a more robust intervention''.
In October 2007 Dixon pleaded guilty to manslaughter on the grounds of diminished responsibility and was ordered to be detained indefinitely in a secure psychiatric unit.
Mental Health Matters have also previously admitted health and safety breaches and been fined £30,000.
A statement by the Trust said:
"We welcome the publication of this report, we accept its findings and we apologise for the shortcomings identified in it.
We particularly extend our condolences to the family and friends of Ashleigh Ewing.
This was a shocking and tragic incident which provides lessons for all the agencies involved and for the wider health and social care systems.
It is important to remember that this tragic death occurred over seven years ago and much has changed since then.
We would also like to reassure Ashleigh's family and the public that since these tragic events, the trust has rigorously and continually impoved the areas of care that have been found by this report to fall short of good practice.''
A statement from Mental Health Matters said they acknowledged there had been failings in its procedures regarding risk assessment and have conducted a thorough review of their procedures.