An inquest into the death of a man killed on a psychiatric ward has found the incident was avoidable and exposed multiple failures in the care of people with severe psychotic illness.
Jury: failings at every stage
Hampshire coroner Nicholas Walker recorded an unlawful killing after determining that the death of Richard Laversuch, aged 63, at Parklands Hospital, Basingstoke, in November 2021 should not have occurred. The jury found that a number of failures by healthcare staff and services contributed to the tragedy.
The man accused of the killing, then aged 18, had been detained on the ward after displaying acute psychotic behaviour and had previously assaulted another patient shortly before the fatal attack. Evidence heard at Winchester Coroner’s Court described the younger patient’s symptoms as severe and escalating in the days before the incident.
Family describe system as 'inadequate'
The sisters of the victim, both of whom have professional experience in NHS urgent care, condemned the handling of their brother and argued the system for people with psychosis is fundamentally flawed. They told the inquest and the BBC that mistakes occurred at multiple stages of care, from community management to inpatient oversight.
"They just don't recognise how serious psychotic illness is,"
One sister said the failings amounted to an unsafe system that could lead to "more deaths, more terrible things happening and more heartbreak for more families" unless substantial changes are made.
Sequence of events
Records presented during the inquest indicated the accused had exhibited delusional beliefs that he was taking part in a game and that he needed to commit mass violence to avoid perceived harm. On 26 November 2021, his parents reported removing weapons from him and informed the NHS community mental health team they could not manage him at home. An urgent Mental Health Act assessment was arranged and clinicians recorded him as a "high" risk to others.
| Date | Event |
|---|---|
| 26 Nov 2021 | Parents report escalating psychotic behaviour and remove weapons; urgent assessment arranged |
| 27 Nov 2021 | Assault on another patient followed by fatal attack on Richard Laversuch |
Concerns about recognition and risk management
The family told reporters they had studied official records, attended hearings and listened to evidence during the inquest. Drawing on their own clinical backgrounds, they said the documents and testimony showed a failure to identify the severity of the younger patient's psychosis and shortcomings in how risk was managed both in the community and on the ward.
Hampshire coroner Mr Walker described the death as "utterly avoidable", reinforcing the family’s view that the episode revealed weaknesses in the pathway for people with severe mental illness.
- Family concerns: Sisters say system is "inadequate" and call for change to prevent further deaths.
- Clinical findings: Inquest identified multiple failures by health staff and services in managing a high-risk patient.
- Juror verdict: Death recorded as unlawful killing.
The case underscores broader tensions in the provision of mental health care: how high-risk individuals are assessed and moved between community and inpatient settings, how wards are staffed and supervised, and how information about escalating risk is shared and acted upon.
Families and clinicians involved in the inquest urged a reappraisal of processes for urgent assessments and inpatient safeguarding so that vulnerable patients and their fellow inpatients are better protected. The sisters’ account—shaped by professional experience and detailed review of records—adds weight to calls for a systemic response rather than isolated changes to practice.
While the inquest determined the immediate circumstances of this death, the broader policy and regulatory response will be watched closely by mental health professionals, hospital managers and campaigners for patient safety. The coroner’s findings are likely to inform local and national reviews of psychiatric inpatient care and risk management protocols.
If adopted, recommendations following the inquest could affect how urgent assessments are triaged, how high-risk patients are monitored in hospital and the resources allocated to ensure wards are safe for all patients and staff. The family has made clear that they see such change as essential to prevent further tragedies.
