Both home and hostel managers and the local authority should be responsible for ensuring that trained mental health professionals work in situations such as the Cyrenian hostel, the inquiry said. Employees should have an NVQ or similar qualification. Social services must specify "clearly and unequivocally" the staffing and other standards required and there should always be experienced, qualified staff available. Police radio operators should be informed of all 999 calls which are cut off, accidentally or deliberately.
The inquiry established a four-year chain of events that led to Jonathan Newby's stabbing by John Rous, starting with too little support for mental health workers in the community in 1989, including support for Rous's key worker. From 1992, the Cyrenians' selection policy led to a concentration at the hostel, originally founded for the homeless, of mentally ill people who would normally have been in hospital.
In April 1993, the Cyrenians failed to train Jonathan Newby in dealing with the chronically mentally ill.
In the run-up to the killing, Audrey Moore, the project leader, is criticised for failing to have compulsorily detained in hospital a disturbed resident who was upsetting Rous. On the weekend Jonathan Newby died, a decision to keep existing staffing levels - leaving him alone - was made. Police then failed to respond to Rous's call and Mr Newby failed to seek advice or help in the apparent belief that he could handle the crisis.
Inspectors who visited the home failed to see that untrained volunteers were being left alone for up to 24 hours, a failing the inquiry says was "reprehensible."
"We find it impossible to accept that the inspectors did not know that this form of staffing had been general through the Cyrenians organisation for several years ... If inspectors were unaware of this basic fact it reflects very adversely on their diligence and/or competence," the report says.
It is also highly critical of Michael Hall, the Cyrenians' director, saying the charity had grown so quickly that it had failed to develop adequate systems for recruitment, supervision and training of staff.
In addition, "It is evident that the management committee of Oxford Cyrenians ... failed in the discharge of their duties. This combined disastrously with the failure of the inspectors' regulation of Jacqui Porter house.
"Furthermore, the network of health, social services and voluntary services was unplanned and disparate, and has been so for many years, thus providing an environment in which expertise was not readily available to untrained workers.
"Therefore appropriate fail-safe mechanisms had not even been discussed between the agencies involved, let alone set in place and tested." One recommendation is that all staff must know what to do and who to contact when an emergency involving a patient arises. And providers of housing with care must satisfy themselves that they can meet the needs of the people referred to them, the inquiry said.
Elizabeth Leyland, the Cyrenians' chairwoman, admitted shortcomings as the organisation expanded to plug the gaps in statutory care. "We did overreach ourselves to meet a need that was not being met," she said. "We hope as a result of this report it will now be met."Reuse content