Ten years ago, mental health worker Ashleigh Ewing was brutally killed whilst out working alone on behalf of her employer, Mental Health Matters (MHM). Ashleigh was stabbed 39 times by Ronald Dixon when she made a routine visit to his home in Heaton, Newcastle. Dixon, who had a long history of disturbing mental health problems, was locked-up in a secure hospital after admitting manslaughter.
In May 2013, a report by an independent panel concluded that a “more robust approach” to Dixon’s care, particularly from April 11, 2006, to the days leading up to Ashleigh’s death, would have resulted in a review as to how appropriate lone visits to Dixon’s home were.
22 year old graduate Ashleigh lost her life after being sent alone to Dixon’s home with a debtor’s letter ordering him to pay for a phone which he had smashed inside the property days earlier, to take the coins from inside.
Was it appropriate to send a young woman unaided to Dixon’s home? According to the independent report, Ashleigh should never have been sent alone.
Dixon had a long and brutal history regarding his mental health state. In 1994, Dixon was convicted of wounding after he admitted creeping into his parents’ bedroom and attacking them with a hammer while they slept.
Then just four months before killing Ashleigh, he was arrested outside Buckingham Palace. He told police his name was King Ron, and he was going to kill his ‘mother’, the Queen.
Dixon was such a threat that he was rated as being among the top 10 most dangerous patients when he arrived at the Rampton Secure Hospital in Nottinghamshire, following his arrest for killing Ashleigh.
The coroner, David Mitford criticised MHM saying the risk, which was evidently high, was not properly assessed. The fact that so much was known about Dixon’s chillingly behaviour before Ashleigh’s death led to many demanding answers about what could have been done to prevent the tragedy.
The independent report commissioned in 2013 and chaired by barrister Joseph O’Brien, came to the same conclusions. “The panel is of the clear view that if a reassessment of risk had taken place, lone working would have ceased prior to May 19, 2006,” said O’Brien.
MHM were fined £30,000 after admitting health and safety breaches.
Since Ashleigh’s death, numerous laws pertaining to health and safety have been passed. The Corporate Manslaughter Act came onto the statute book in July 2007 as the ‘Corporate Manslaughter and Corporate Homicide Bill’, and became effective on 6th April 2008. The Act clarifies the criminal liabilities of companies including large organisations where serious failures in the management of health and safety result in a fatality. Could MHM have faced prosecution under this Bill had it been passed in time?
An organisation will be found guilty of the offence of Corporate Manslaughter if the way in which any of its activities are managed or organised by its senior managers causes a person’s death, or amounts to a gross breach of the Duty of Care it owed to the deceased. The fact that the independent report and the coroner’s report both concluded that the risk posed was not properly assessed could’ve been damming.
David Mitford concluded that, “Mental Health Matters lacked their own assessment of the risk Mr Dixon presented and there were shortcomings in their systems that led to a failure in realising the significance of changes to him. In particular, that he’d stopped taking his medication, his paranoid schizophrenic, excessive drinking, his forensic history and his actions in London.”
Since Ashleigh’s death, Dr Rajesh Nadkarni of the local Northumberland, Tyne and Wear NHS Foundation Trust, has vowed that the tragic events have “led to significant improvements in practice.”
“One of the main changes since Ashleigh’s death and the report which followed is how we work together with other organisations and much has been undertaken to strengthen both joint working and the sharing of information between agencies.
“Another improvement to come out of this tragedy has been the work done to ensure the safety of ‘lone workers’. Although Ashleigh didn’t work for us, her death caused us to consider and review how best we can safeguard staff during home visits.”
Lone working in general has become more prevalent in the last decade across all industries and sectors as organisations have cut costs in times of budgetary restraints… especially in the public sector where funding has continually been squeezed.
With legislative penalties on the increase (major companies convicted of corporate manslaughter will face fines of up to £20m under sentencing guidelines), never has the Duty of Care to all employees – whether they work alone or not, been so important.
With advances in technology, specifically in communications, contact with lone workers has never been easier. In 2006, the iPhone hadn’t even been launched and smartphones were stuff of dreams.
Apps, 4G coverage and touch screen technology have vastly improved how we communicate.
Violent attacks will continue to happen. But equipping lone workers with a ‘buddy system’ or a means to easily call for help in an emergency has arguably saved countless lives in the last few years alone. It’s a tragic shame that it’s all come too late for Ashleigh. However, her legacy has certainly improved lone working practices and for that, she will always be remembered.
As Nadkarni concludes, “I hope it may be some small comfort to Ashleigh’s family that her death has brought about real changes and improvement in practice that will reduce the potential for such devastating and life changing events occurring in the future.”