Wholesale failures in the Alex Lewis-Ranwell case: the jury's findings into the deaths of Anthony Payne and Dick and Roger Carter

A Coroner’s jury sitting in Exeter has returned a stinging set of conclusions in the case concerned with the three elderly men killed in 2019 by Alex Lewis-Ranwell during a psychotic episode.

On 10 February 2019 Lewis-Ranwell, then aged 28, killed Anthony Payne, and twin brothers Dick and Roger Carter, having been released from police custody just a few hours earlier. All three men were in their 80s, and Lewis-Ranwell, following several days of psychosis, appears to have believed they were paedophiles. None of the men were known to Lewis-Ranwell, and the Carters and Mr Payne were also strangers to each other. All were innocent and gentle men going around their business until they were killed by Lewis-Ranwell using household and gardening tools that he found in their homes.

Lewis-Ranwell had a history of psychosis and violence and was well known to the police. He had previously been sectioned in 2016 and 2017, with both a diagnosis of drug-induced psychosis and schizophrenia. In 2018 he spent time in France before returning home where, following a Christmas party where he had used drugs, he began to behave oddly. On 8 February 2019 he was arrested following a series of events at a pub and two farms where members of the public and arresting officers all agreed it was “mental health” and that he would “cause havoc” if left free. He was taken to Barnstaple police station – the same station where he had been held less than two years earlier – where his mother rang in with a detailed account of the symptoms Lewis-Ranwell would be showing were he descending into psychosis. He was exhibiting all of those symptoms, but Mrs Lewis-Ranwell’s warning was not recorded in the detention log so others could not see it.

In the early hours of 9 February 2019 Lewis-Ranwell was released to a local hostel where he soon started showing symptoms again. The manager of that hostel recalled him looking at an old man in a newspaper and starting to talk about paedophiles. Lewis-Ranwell left the hostel and a few hours later, attacked a local farmer with a four and a half foot logging saw. He accused that farmer of being a paedophile too.

That incident was so serious that armed police were called, and they arrested Lewis-Ranwell following a pursuit across farmland on a farmer’s quadbike. Lewis-Ranwell was returned to Barnstaple police station where a mental health practitioner from Exeter spoke to him on the phone before concluding that he clearly required a Mental Health Act assessment. That practitioner was however overruled on the (also wrong, it turned out) basis that a face-to-face assessment was required first. That resulted in a police doctor – a forensic medical examiner (“FME”) – employed by G4S being called.

The doctor decided that Lewis-Ranwell did not in fact require a further assessment. Overruling the by then clear view of all in the custody suite, the doctor decided Lewis-Ranwell was not acutely unwell and was fit to interview. The investigating officer who knew Lewis-Ranwell from 2016 carried out that interview, and the jury saw a video of it. He was obviously not fit for interview, yet he remained without a Mental Health Act assessment. Other evidence also showed that throughout this period Lewis-Ranwell remained seriously, and visibly, unwell.

The jury would later hear that the doctor had little or no mental health experience, and in fact had not met the requirements to be employed as a FME at all. However, no-one at G4S had picked that up at the time nor even through the criminal proceedings or internal reviews. It emerged for the first time on the final day of the evidence at the inquest. The doctor’s main experience had been as a senior house officer on orthopaedic wards.

The police considered whether or not to go behind the doctor’s assessment, but the jury heard that the custody sergeant had believed that the relevant police power was not available in police custody. He had missed a relevant legislative change. Other officers said they believed they could not go behind a doctor’s assessment. The jury heard that too was wrong. The key failure was therefore that of the doctor, but the police’s safety net also failed.

Lewis-Ranwell was therefore released on the morning of Sunday 10 February 2019. He travelled to Exeter and killed Anthony, Dick and Roger a few hours later, but their bodies were not discovered until 11 and 12 February. By then, Lewis-Ranwell was back in custody having attacked a receptionist at the Rougemont Hotel nearby. The jury also heard evidence about a wider trail of bizarre and threatening behaviour from Lewis-Ranwell since his release. Several members of the public had encountered him.

On 2 December 2019 Lewis-Ranwell was found not guilty by way of insanity of the three killings. The same day, G4S gave a public statement saying they “stood by their FME”. It was only during questioning in the inquest, more than seven a half years later, that the former head of the G4S service, Jonathan Allen, began to accept that things might have gone wrong. Mr Allen told the court that G4S was no longer doing any work in the area of mental health.

Following a hearing lasting five weeks key parts of the jury conclusions were that the following all made a probable contribution to the death of Anthony Payne, and Dick and Roger Carter:

• The shortcomings by Devon and Cornwall Police in information gathering, sharing and recording, including in not communicating with Lewis Ranwell’s mother, and relying on oral handovers which gave rise to “vital information being lost”.
• Systemic failures by Devon County Council and Devon Partnership NHS Trust in terms of misunderstanding the circumstances in which a face-to-face assessment would be required.
• A “fundamental” misunderstanding by the G4S doctor as how to carry out a mental state examination, with “clear signs of delusion and disordered thinking” ignored by the doctor.
• Poor management and mixed understanding of s.136 of the Mental Health Act 1983, which should have been used by police on the morning of the killings due to Lewis-Ranwell’s “continued aggressive behaviour” and “presentation typical of his psychosis”.
• “Significant evidence of a complete disregard by G4S” for their tender practices and thus “patient safety” which meant that the doctor was recruited when he was not qualified, and then with systems incapable of identifying critical knowledge gaps, and reliance on appraisee led appraisals that were deeply flawed.

Commenting on the conclusion Bharine Kalsi, acting for the Payne and Carter families said:

“The scale of the failures in this case are breathtaking. The core of this is of course the wholesale failure of the G4S doctor, who maintains his errors to this day, despite them being pointed out repeatedly, and G4S’ poor recruitment practice. But there is also a much wider issue about the capacity of police systems to pick up when another part of the system has failed, and about mental health awareness of officers. Time and again in this case we saw the police missing signs that were obvious to members of the public. That looks like wholesale desensitisation by those who should be alert. It requires urgent action including at national level.”

Amanda Taylor, niece of the Carter twins, said:

“Nearly eight years after the brutal killings of our uncles, Dick and Roger Carter, we finally feel that the inquests have exposed the systemic failures and missed opportunities that cost them their lives. We are grateful to the Coroner, his team and our legal team for their thorough examination of the evidence, and to the jury for reaching a conclusion that reflects the gravity of those failures. While nothing can undo our loss, we hope that the findings will lead to meaningful, lasting change across all organisations involved. We believe the evidence heard during the inquests demonstrate the need for a national review of guidance and training on mental health in police custody, so that meaningful lessons are learned, and similar failures are not repeated. Further, private companies such as G4S who have been outsourced to provide public services need to be scrutinised. Dick and Roger’s death must lead to lessons being learned nationally, so that these failures are not repeated and other families are spared the devastating loss we have endured.”

The Payne family:

“Whilst the conclusions are difficult to hear, we thank the jury for their diligence. We can only hope that the agencies listen to this damming conclusion and take stock of the changes that need to be made to ensure this doesn’t happen again to another family.”

The families of Anthony Payne, and Dick and Roger Carter are represented by Bharine Kalsi and Rachel Tribble of DPG and Nick Armstrong KC and Danielle Manson of Matrix.