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

1st Dec 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 inquest, Lorna’s family described her as an “amazing lady” whose “radiant smile”, kindness, and generosity lit up every room. They recounted how she was a devoted wife, mother, grandmother, and active member of her community, who believed in “living life fully”.

Her husband of 52 years spoke of Lorna as his “soul mate” and “guiding light,” and her loss has left her family with a “permanent empty void”.

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, and whilst the coroner did not pursue 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