Inquest Highlights Failings in Mental Health and Multi-Agency Support in the Killing of Lorna England

10th Nov 2025

On 18 February 2023, 74‑year‑old grandmother Lorna England was tragically stabbed to death while walking home through Ludwell Valley Park, Exeter, by Cameron Davis, a man with known mental health issues. Davis, aged 31 at the time, was later convicted of her murder and sentenced to a minimum of 28 years in prison.

During the recent inquest, Lorna’s family released a statement about Lorna, and what her loss means to the family:

“Known fondly as ‘Lovely Lorn’ by those close to her, Lorna was a beloved wife of 52 years, mother, grandmother and sister. She was a kind and loving lady who lived life to the full and was the most content person you could ever wish to meet.

“Her smile lit up the room and her gentle nature made everyone feel welcome and loved. She had a quiet strength and a generous heart; always putting others before herself.

“Lorna enjoyed spending time with her family whether that was holidays with her husband, an exercise class with her daughter or a spot of DIY with her son. She loved to stay healthy because she wanted to be around for as long as she could to enjoy special times with her family – something which has now been so cruelly stolen from us.”

The family want to express their gratitude to the emergency services who helped Lorna, the Major Crime and Investigation Team at Devon and Cornwall Police and to a witness who challenged Cameron Davis after the attack risking her own life while helping Lorna.

The family added: “We all have a permanent empty void because we miss Lorna so much. From the moment we wake up, we relive the shock and horror that she is no longer with us and we take that to bed every night.

“We will never come to terms with the death of such a wonderful lady. How do you ever make sense of such a wicked act?”

Key Inquest Findings

The inquest which took place at Exeter and Greater Devon Coroner’s Court had several key findings:

1. Mental Health Support Breakdown

• The inquest heard that Davis had fallen off a waiting list for a care coordinator, a lapse possibly caused by a cyber‑attack on Devon Partnership Trust’s IT systems.
• The senior coroner, Philip Spinney, determined that had Davis been allocated a care coordinator, this might have triggered a Multi‑Agency Risk Assessment Conference (MARAC) to address his escalating risk.

2. Multi‑Agency Failings

• The evidence raised serious concerns about the effectiveness of inter-agency information-sharing.
• Housing support staff and clinicians had attempted to escalate concerns, warning Davis should perhaps have been sectioned days before the murder. However, no single agency took ownership of these warnings.

3. Police 101 System Failings

• A clinician reported being placed on hold for over two hours while contacting police about Davis’s threat to kill someone if not detained.
• The coroner acknowledged failings within the police 101 system, although ultimately, it concluded that no direct act by public bodies caused Lorna’s death.

The Verdict

The senior coroner returned a verdict of unlawful killing, stressing that Lorna’s death “could have been avoided” had agencies acted earlier. While the coroner did not issue a Prevention of Future Deaths (PFD) report, the findings underscore urgent systemic vulnerabilities.

Hollie Muckley represented Lorna’s family at the inquest. Hollie says:

“Changes need to be made in how potentially dangerous individuals are dealt with in the community. For Lorna and her famliy, the 18th February 2023 started off as a normal Saturday. Lorna decided to walk to the shops as she wanted to achieve her daily 10,000 steps and didn’t know the horror that was awaiting her.

“Two years on and the family is still struggling to make sense of what happened. Why hadn’t the police, clinical staff and housing agencies been involved in a multi-agency risk meeting about Davis? Why hadn’t Devon Partnership Trust added Davis to a waiting list in relation to his mental health when they were aware of his problems a year before Lorna’s death. And why hadn’t the police responded to the 101 call from clinicians to report the threats Davis was making on the day he murdered Lorna?

“Knowing that Lorna’s death could’ve been avoided continues to torment her heartbroken family and the only thing they can hope for now is that lessons are learnt so that this never happens to another family.”

The inquest gained widespread media attention, including reports published in The Guardian, BBC News, and Devon Live.

At HCC Solicitors, we are committed to supporting families seeking accountability and change. Lorna’s family, represented by us, voiced the hope that these findings will lead to improved safety measures and better protection for vulnerable individuals. If you want to know how we can help with you, get in touch with one of our experts