A coroner has found there were "failures to monitor" the man who killed Michael Matthews in a secure Newcastle mental health unit, but ruled that this failure had not "more than minimally, negligibly or trivially contributed" to Mr Matthews' death.
Michael Matthews was violently attacked in his room on the Fellside Ward of the Hadrian Clinic in Newcastle in April 2022 by Ahsan Zia. He suffered "head and facial injuries" which led to cardiac arrest - and he died days later at the Royal Victoria Infirmary.
Coroner's findings on monitoring failures
Newcastle and North Tyneside senior coroner Georgina Nolan delivered a formal conclusion on Friday morning after hearing evidence between September 21 and 23 this week. She ruled that Mr Matthews' death had been an unlawful killing.
Ms Nolan highlighted that during the year prior to the attack, Zia had expressed a wish to come off one of his anti-psychotic medications. She recounted how on one occasion he had contacted his care team immediately after a medication review to express a "totally different view".
Ms Nolan said: "Surprisingly that conversation does not appear to have raised any significant concern or intellectual curiosity with the professionals treating him."
Evidence on violence prevention plan
The coroner also did not agree with an NHS witness who had told the court that a specialist violence prevention plan had not been appropriate. During his evidence on Wednesday, CNTW NHS Trust's deputy chief operating officer Russell Patton told the court he had not seen, in his own investigation, that it would have been appropriate to carry out a specific "Prevention and Management of Violence and Aggression" plan in Zia's case.
However, Ms Nolan said: "I do not accept Mr Patton's evidence that a Prevention and Management of Violence and Aggression plan was not appropriate." She continued: "However I do not find this contributed to Mr Matthews death - or that any change to observation levels would have prevented the attack upon him."
Background and family tribute
The attack - which lasted less than 30 seconds - was carried out on April 13 2022, with Michael being pronounced dead on April 17. The court had heard how Zia had been diagnosed with schizophrenia and had a history of aggression and violence while acutely unwell. Zia was originally charged with murder but pleaded guilty to manslaughter on the grounds of diminished responsibility. At Newcastle Crown Court in 2023, he was sentenced to an indefinite hospital order.
Ms Nolan also found there had been a "failure to act on blood test results" which also showed Zia had stopped taking the drug. The coroner found that the consultant psychiatrist responsible for Zia's community treatment had called Fellside Ward in the days before the attack warning that: "Mr Zia had a history of violence. That risk was historic but it was known to be a risk when he was unwell."
At the beginning of the hearing this week, a statement from Mr Matthews' family was read by the coroner. This said: "[Michael] was a loved son, loyal brother, proud uncle, and cherished friend. He grew up in Dorset and had a deep love of the outdoors. He loved fishing, camping and spending hours at his favourite beach with a packed lunch, his fishing rod and the calm of the sea. Those were the moments that made him happiest, calm and free."
His family said that in his youth, Michael "excelled in athletics" and had a "quiet, competitive spirit". He was said to be "nurturing and deeply protective" of his younger brother and sister. The inquest heard that after being made redundant from a job at the Royal Navy dockyard in Portsmouth, Michael moved to Newcastle for a fresh start with a close friend.
His family added: "His death left a void in our lives, he was deeply loved by his family and his absence is felt in one hundred different ways. Special occasions feel less special without him, a reminder of the space he once filled so naturally, and the love that will always remain."
Zia remains under a hospital order and while he was formally an "interested person" in the coronial proceedings, he declined, through his psychiatrist, to participate. The CNTW NHS Trust has been approached for further comment.
