A FAILURE to act on a psychiatric patient telling his social worker he was in possession of a knife days before he stabbed a man to death in Poole has led a coroner to order change at a health trust.

Paul Taylor was under the care of mental health services when he killed Ryan Merna at a flat in Ashley Cross.

Richard Middleton, assistant coroner for Dorset, concluded that 29-year-old Mr Merna had been unlawfully killed following an inquest in March.

Mr Middleton found there was a “missed opportunity” to reassess the risk Taylor posed to others in light of new information disclosed five days before Mr Merna’s death.

Bournemouth Echo: Ryan MernaRyan Merna

Mr Merna died from injuries sustained in the knife attack at his home in Wessex Road on August 14, 2016.

Taylor, who was aged 50 at the time, was convicted at Winchester Crown Court of the offence of manslaughter of the grounds of diminished responsibility.

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He was detained indefinitely through a hospital order under the Mental health Act in September 2017.

Mr Merna had been stabbed 32 times by Taylor, who he had previously allowed to live in his flat when the offender was homeless.

Following the inquest, Mr Middleton wrote to the chief executive of Dorset HealthCare University NHS Foundation Trust, the organisation responsible for Taylor’s care through the mental health team at St Ann’s Hospital in Canford Cliffs.

The coroner’s preventing future deaths report says a forensic social worker accompanied the perpetrator to an assessment meeting at a possible housing provider.

“During the course of that meeting the perpetrator disclosed that he was in possession of a knife, that he was sleeping rough and he needed the knife for his own protection,” the report says.

Read more: Family pays tribute to Ryan Merna as Paul Taylor is found guilty of manslaughter

The following day during a meeting involving Taylor, the social worker, a psychiatrist and a care coordinator, the disclosures made at the housing assessment were not raised. In addition they were not documented.

Expressing his concerns, Mr Middleton’s report says: “The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping.

“The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the social worker.

“The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator's records.

“The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure.”

Mr Middleton has urged Dorset Healthcare to make changes to the trust clinical risk policy.

He said it should make reference to: “The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain.

“Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the trust and/or the police to be documented.”

A spokesperson for Dorset HealthCare said: “We accepted the Assistant Coroner’s conclusion about how Ryan died in 2016. As a Trust, we have worked hard to learn from this tragic event and have been reflecting further on details considered during the inquest in March this year.

“We are carefully reviewing the action points outlined in the Assistant Coroner’s report and will make changes to try to minimise the risk of such a tragedy ever happening again.”