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Tamara Holboll inquest: Camden’s mental health trust cancelled hospital bed search for schizophrenic killer

PUBLISHED: 10:26 21 April 2015 | UPDATED: 10:50 22 April 2015

Peter Holboll pleaded guilty to manslaughter on the grounds of diminished responsibility last year

Peter Holboll pleaded guilty to manslaughter on the grounds of diminished responsibility last year

Archant

Camden’s mental health service cancelled its search for a hospital bed for a paranoid schizophrenic who then went on to kill his mother, a court has heard.

Camden and Islington NHS Foundaton Trust (C&I) came under intense scrutiny at an inquest on Monday into the killing of 68-year-old Tamara Holboll, who was stabbed to death by her son Peter, now 45, in May last year.

The court heard that Ms Holboll and her son had pleaded for him to be sectioned, but were told by health professionals that no hospital beds were available.

Two days later, he killed her and set ablaze her flat in Lawford Road, Kentish Town, endangering the lives of five people living above. He was detained after pleading guilty to manslaughter due to diminished responsibility and arson at the Old Bailey last year.

It emerged at the inquest at St Pancras Coroner’s Court that the trust cancelled its search for a bed, without informing his doctors or nurses.

The trust has suffered a serious squeeze on beds since it axed more than 100 beds in four years, between 2011 and 2014.

Senior coroner for inner north London Mary Hassell gave a narrative ruling, and said: “Admission was agreed but no beds were immediately available. “Then, confusion about arrangements within the mental health trust following involvement by the recovery and rehabilitation team and the crisis team emerged the following day.

“Unbeknownst to them, the search for a bed had been stopped.”

No-one from C&I’s bed management service was put in the dock to answer for why the search for a bed was cancelled.

When the Ham&High asked the trust why it had cancelled the search, it said the bed management service believed Holboll was being “successfully treated in the community”.

Since the incident, the C&I has made changes to its bed management service to improve internal communications, and has put in place a 17-point action plan.

On May 7 last year, Ms Holboll rang mental health service the South Camden Recovery and Rehabilitation (R&R) Team to ask them to admit her son to hospital, telling them: “I’m afraid he will harm me”.

He was assessed by mental health workers, and it was agreed that the C&I would try to find him a bed. They were told that five other patients were also on a waiting list for a bed.

But one mental health worker admitted that he believed Ms Holboll was being “overly dramatic” - a statement wrongly denied by the C&I last year. The trust has since apologised for the mistaken denial.

Several mental health workers who saw Holboll in the two days before his mother’s death told the court that he would have been admitted to hospital if a bed had become available.

But they all said that they did not believe there was any “imminent risk” to his or his mother’s safety, and that his behaviour had “improved” the day .

Between 2011 and 2014, C&I lost the second-biggest proportion of beds of any mental health service in England, with 19.1 per cent being scrapped.

The closures meant nearly 200 patients have had to be sent elsewhere for treatment since 2011.

A spokesman for C&I said: “This is an extremely tragic incident and our sincere condolences are extended to Tamara Holboll’s family.

“We have been deeply saddened by her death which has greatly affected the staff who both knew her and her son.

“Our clinicians work in extremely difficult situations. They make assessments on people who may be suffering a psychotic episode, paranoia or some other complex condition and help thousands of people live as near normal lives as possible.

“We are continually improving services and in so doing try and prevent such serious incidents from happening again.”

Ms Hassell is to make a Prevention of Future Death report, a document to set out lessons learnt and changes that could be made to prevent deaths.

She ruled Ms Holboll’s death was unlawful, and said: “I am trying to help you all learn from this.”

She later added: “Whatever the public at large may think, this crime was very, very unusual.”


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