Risk posed by woman who killed man in shop 'insufficiently assessed'

The risk of harm posed by a woman with psychosis who bludgeoned a pensioner to death in a shop had been "insufficiently assessed and addressed" in the run-up to the attack, a coroner has concluded. A four-day inquest into the death of John Rees, 88, at Pontypridd Coroners' Court heard evidence about the events in the run-up to the fatal attack in a Co-op store in Penygraig, Rhondda Cynon Taf, on May 5, 2020.

Zara Radcliffe, 30, of Porth, had been discharged from hospital less than three months before the incident, as she had been deemed a "low risk to others". She was experiencing a psychotic episode on the day she killed Mr Rees, having left her family home with a kitchen knife, the coroner's court heard.

The inquest found Radcliffe’s psychosis was unmedicated and "not being assessed or managed" around the time of the attack. Mr Rees had attempted to intervene when Radcliffe had pointed the knife towards another person in the shop before she went on to stab him, while his wife Eunice, 87, was waiting in the car outside, oblivious to what was happening. For the latest Welsh news delivered to your inbox sign up to our newsletter

Read more: Cardiff hotel evacuated after man allegedly found with gun

Read more: Police issue update on triple crossbow killing suspect Kyle Clifford

Radcliffe then struck Mr Rees, a retired electrical engineer and a church bell ringer, to the head with wine bottles and a fire extinguisher more than 20 times as he slowly lost consciousness. Radcliffe had also stabbed others in the store, who survived. Pathologist Dr Richard Jones determined Mr Rees' medical cause of death was severe blunt force trauma to the face including multiple facial fractures.

Radcliffe was detained with an indefinite hospital order after admitting to manslaughter by diminished responsibility. She was sentenced in October 2020, with Mrs Justice Jefford saying she had made that decision due to the risk Radcliffe posed to the general public.

'I had a feeling something would happen'

Radcliffe had previously been admitted to Royal Glamorgan Hospital in Llantrisant in November 2019. Her sister, Kylie Radcliffe, told the inquest she had been concerned when Radcliffe had been discharged in February 2020, despite having been diagnosed with schizophrenia during her stay and put on daily anti-psychotic medication.

A risk assessment in January 2020 concluded Radcliffe's psychotic symptoms had "diminished" and she was "compliant with her medication". Kylie Radcliffe told the hearing her sister spoke about having "voices in her head" and claimed there was no after care for her when she left hospital.

“I had a feeling something would happen,” she added. The inquest also heard it appeared that Radcliffe had not been taking her antipsychotic medication properly in the weeks and months before the attack, with her then partner saying he rarely saw her take any tablets.

Radcliffe's GP told the hearing he would expect the local mental health support team to ensure she was taking her medication. He also said Radcliffe had tested positive for cannabis and cocaine - the former 12 days after her risk assessment in January 2020 and the latter day before she was discharged from hospital. She would take drugs occasionally while on leave from the hospital, the inquest heard.

Radcliffe's mother Elaine Radcliffe also claimed the family were told social workers would visit her daughter regularly but that didn't happen and she was "not sure whether that was down to Covid."

Care coordinator 'didn't really know Zara'

The inquest heard how the local mental health support team was aware Radcliffe had been hearing voices in her head but care coordinators had not been concerned by her presentation. But the hearing was also told that they had just two consultations with Radcliffe between February 2020 and the day she killed Mr Rees – and one of those was on the phone due to Covid restrictions.

Radcliffe's primary care coordinator Laura Morse - who was allocated to her by Rhondda Cynon Taf’s local authority community mental health team in the months before the attack - told the court she "didn't really know Zara that well" and didn't have an "in-depth rapport" with her.

The hearing heard how on the morning of Mr Rees’ death, Radcliffe’s father, Wayne, had left home, sat outside in his car - fearful to go back inside in case it sparked an "argument" - and rang local mental health teams expressing concern for his daughter's mental health.

He said he "sat in the car for hours" waiting for the mental health team to get back to him but he said they didn't ring. After she killed Mr Rees, Radcliffe said to police she was told to do it by the voices in her head and told officers words to the effect of, "I knew I was going to kill someone today".

Risk of harm to others 'insufficiently assessed and addressed'

Delivering his findings on the final day of the inquest on Thursday, July 11, senior coroner Graeme Hughes said the interactions the community mental health team had with Radcliffe following her discharge were "insufficient" and on the balance of probabilities this "more than minimally, negligibly or trivially contributed" to the pensioner's death.

He recorded a narrative conclusion. He said: "On May 5, 2020, whilst visiting the convenience store in Tonypandy, John Rees was beaten and killed. His assailant was convicted of manslaughter. At the time of the acts that caused his death, his assailant’s psychosis was not being medicated and her risk of harm to others was insufficiently assessed and addressed."

He added: "The deceased was unlawfully killed. His assailant was suffering from psychosis which was unmedicated and not being assessed or managed at the time of or approximate to the events leading to his death."

In May 2023 Cwm Taf Morgannwg University Health Board apologised for “any instances in which her [Radcliffe’s] care fell short”. An independent review commissioned by Cwm Taf Morgannwg safeguarding board concluded “warning signs” of Radcliffe’s “rapid deterioration” were apparent before the pandemic but these were “not recognised or poorly processed”. It said the decision-making capability of Radcliffe was not questioned and there was “no negotiated crisis plan” before she was discharged from hospital.

In February 2024 Mr Rees was honoured with the Queen’s gallantry medal for his bravery during the incident. It was accepted on his behalf by his granddaughter Madeleine Davidson-Houston. Lisa Way and Ayette Bounouri were also awarded Queen's gallantry medals for their efforts to stop Radcliffe.

Speaking after the inquest, Ms Bounouri said: "We have seen what we needed to see and hopefully the memory of Mr Rees will keep going." She added that she will be "mentally affected" by the incident for the rest of her life. "You just learn to live with the trauma...for the victims and the witnesses, like myself, of the incident, it's something you just will never get over."