A man was strangled to death by a fellow patient on a psychiatric ward following failures by health staff, an inquest jury has found. Owen Herbert, then aged 18, attacked 63-year-old Richard Laversuch in the early hours of 27 November 2021 at Parklands Hospital in Basingstoke, Hampshire.
In a narrative conclusion, the jury in Winchester said Laversuch, from Andover, was unlawfully killed after Herbert was incorrectly admitted to a less secure ward. Hampshire coroner Nicholas Walker said: "Poor decisions were made one after the other."
In a statement, Hampshire and Isle of Wight Healthcare NHS Foundation Trust said: "Richard should have been safe on our ward and we failed him."
Herbert was detained under the Mental Health Act in November 2021 because he had been hearing voices and had left his home in Overton, Hampshire, with weapons, the court heard.
He believed he was "in a game" and would be "tortured" if he did not kill someone, the jury was told.
Minutes before killing Laversuch, he tried to strangle another patient.
However, when staff investigated that patient's report, they found Herbert in bed and "doubted the account of the attack", the jury concluded.
Laversuch and Owen Herbert were both patients at Parklands Hospital.
The jury said an approved mental health professional (AMHP) from Hampshire County Council incorrectly named a lower-risk ward when Herbert was admitted to the hospital.
When the teenager arrived, no Psychiatric Intensive Care Unit (PICU) bed for higher-risk patients was available, jurors found.
Herbert was admitted to the understaffed ward, even though those on shift had previously been told it was unsuitable for him, they said.
Following his admission, staff carried out an inappropriate risk assessment based on "brief observations of the patient under staffing constraints".
They "placed an over-reliance on the calm presentation of the patient," the jury concluded.
Cathy Laversuch (left) and Bridget Ryan say their brother and his killer were both victims of care failures.
The coroner said: "I cannot imagine how hard it would have been for Richard's siblings to learn how easily his death could have been avoided."
He added he would be writing a Prevention of Future Deaths Report on admissions procedures and risk assessing patients.
Laversuch's siblings, Cathy Laversuch and Bridget Ryan, said their brother and his killer were both victims of "systemic failings" in psychiatric care.
In a statement, they said: "Richard's death was caused by failures to adequately intervene in Owen's care at almost every stage despite Owen's earlier pleas for help."
Herbert, who previously pleaded guilty to manslaughter, was given an indefinite hospital order in 2023 and is detained at Broadmoor Hospital.
Profoundly sorry
Following the inquest, the NHS trust apologised to the men's families and said it had made many changes as a result of the death.
Chief executive Ron Shields said: "I am profoundly sorry for the gaps in our care.
"We have strengthened communication and decision-making around access to the right beds, increased senior nursing presence on the wards day and night, and strengthened clinicians' ability to assess risks and escalate concerns."
A Department of Health and Social Care spokesperson said: "Our thoughts are with the loved ones of Richard Laversuch.
"This government is determined to improve mental health services. That's why we have invested record amounts into the NHS and recruited thousands of additional mental health workers to improve access to care."
They added: "While we know there is more to do, later this year our Mental Health Strategy will outline how we plan to build a mental health system that responds earlier and reduces waiting times for support."
Hampshire County Council has also been approached for comment.
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