Coroner reveals missed opportunities to stop mentally ill man stabbing elderly parents more than 100 times with bayonet during psychotic frenzy

A coroner has highlighted a series of failings in the care of a mentally ill man who killed his elderly parents and called for “urgent action” to prevent a similar tragedy in the future.

James Andrews, known as Duncan, was first given an “urgent referral” by his GP in November 2020, but was followed by “significant delays” in treatment and “refusal of referrals”.

This was despite Andrews saying he had heard voices in his head and, in April 2022, reported how he was having a “severe psychotic episode” where he “thought I was going to kill someone”.

A coroner has highlighted a series of failings in the care of a mentally ill man who killed his elderly parents and called for “urgent action” to prevent a similar tragedy in the future. James Andrews, known as Duncan (pictured), was first given an “urgent referral” by his GP in November 2020, but was followed by “significant delays” in treatment and “rejection of references”.

Bryan, 79, and Mary Andrews, 76, were killed by their son who stabbed his father nine times and his mother 82 times while suffering from a hallucinatory psychotic episode.

On 27 November 2022, Andrews, now 53, struck at the home of his parents Bryan, 79, and Mary, 76, in Totley, Sheffield, stabbing his father nine times and his mother 82 times while suffering from a psychotic and hallucinatory episode.

Police found Andrews standing on the stairs “covered in blood” and holding a knife, having stabbed himself in the stomach, telling officers: “I’ve just killed my mum and dad.”

He previously told paramedics that he had been hearing voices for 14 months and that “God had told him to do what he had done”.

Andrews was detained indefinitely in July last year under the Mental Health Act after admitting manslaughter due to diminished responsibility at Sheffield Crown Court.

Coroner Tanyka Rawden has written a Prevention of Future Deaths report looking into the murders of Mr and Mrs Andrews.

Police found Andrews standing on the stairs “covered in blood” and holding a knife, having stabbed himself in the stomach, telling officers: “I just killed my mom and dad.” Pictured is Andrews’ mother, Mary

Bryan and Mary Andrews were found dead on 27 November 2022 at their home in Sheffield

He has written to Sheffield Health and Social Care (SHSC) NHS Foundation Trust, which runs mental health provision in the South Yorkshire city, identifying more than half a dozen concerns, saying: “In my view, there is a risk that future deaths will occur unless action is taken.’

Ms Rawden said the failings included the “lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths”.

The previous criminal case heard that epilepsy medication may have made him more susceptible to mental health problems.

In November 2020, Andrews’ GP made an urgent referral for higher level treatment after he reported suicidal thoughts, which was declined with surgery advised for assessment through his nurse mental health

Andrews was later referred to a team of specialists, but after he contacted them in April 2022 fearing he would kill someone, he was referred for home treatment, without informing his consultant neurologist .

On May 3, 2022, an antipsychotic medication trial was discussed, but a review of whether it was appropriate to prescribe with Andrews’ epilepsy medication was not conducted.

Andrews was detained indefinitely in July last year under the Mental Health Act after admitting manslaughter due to diminished responsibility at Sheffield Crown Court.

A day later, a referral to an Early Intervention Service was refused because he “did not meet the criteria for first episode psychosis, despite clear evidence of psychosis”, Ms Rawden said.

An email referring Andrews to the Emotional Wellbeing Service (SHSC) was sent on May 5 to an address that was not found on a daily basis. When a response was finally given, it was unclear whether it had been accepted.

A team that discharged him on May 9 did not send details to Andrews’ GP.

And another chance to help Andrews was missed on 4 October 2022 when a GP’s report highlighting ‘paranoia, delusional tendencies and suicidal ideation’ was treated as a ‘routine referral’ by mental health doctors.

Ms Rawden, who returned verdicts of unlawful killing for Andrews’ parents, said the referral was not made until November 22.

During Andrews’ prosecution at Sheffield Crown Court, it was said there had been concerns about Andrews’ health before the murders and he had told her how he was “scared of hurting others”.

Prosecutors said one of Andrews’ sisters noticed him at his parents’ home days before the murders in an “agitated” state with a “knife in a sheet”, which she “took from him”.

Andrews’ sisters Lucy and Sally said they were “let down” by authorities for more than a year and believed their parents would still be alive if the mental health team had diagnosed and treated them earlier.

They said Andrews was “failed by the system” and the family were victims of “broken health and social services”.