Coroner tells organisations to take preventative action after decapitation killing

A senior coroner has called on three organisations to take action to prevent future deaths after a man was killed outside his home in Birmingham.

In her Prevention of Future Deaths (PFD) report, Birmingham and Solihull senior coroner,  Louise Hunt, highlighted failings around the killing and decapitation of Matthew Lynch in 2023 by Kyle Doughty, with whom he shared supported accommodation.

Ms Hunt wants Birmingham and Solihull Mental Health Trust, Birmingham City Council and Provident Housing to provide details of actions they took and explanations for failings in the case. 

Doughty, then 33, was sentenced to an indefinite hospital order after pleading guilty to manslaughter on grounds of diminished responsibility, at Birmingham Crown Court in July 2024.

He had killed 43-year-old Mr Lynch outside their shared property in Ashwin Road, Handsworth, on 11 July 2023.

In her PFD report Ms Hunt also asked for details of a timetable for action the organisations might have drawn up in relation to dealing with Doughty's case.

She said an internal investigation at the mental health trust had not addressed how, and whether, Doughty's use of medication should have been monitored, following a clinic visit he made in May 2023.

The senior coroner said: "This was important as non-compliance with medication was a risk factor for relapse."

The day before Mr Lynch's killing, Doughty had been evicted from the Ashwin Road property after smashing up his room.

In the run up to the murder, Ms Hunt's report noted the trust had not verified whether failed attempts to visit Doughty had been made at an old address, or his new one in Ashwin Road.

Ms Hunt said: "This was a critical issue as the new address had not been updated on the clinical notes."

She said Doughty was known to suffer from "treatment-resistant paranoid schizophrenia", which was made worse if he stopped taking medication and took illegal substances.

Ms Hunt also noted that there were concerns about whether the trust was adequately learning from incidents Doughty was involved in.

The coroner’s report also set out concerns about resistance to working with mental health professionals between both the trust and the city council.

She said that such a lack of co-operation could have led to appropriate mental health assessments not taking place.

Her report noted that there were also concerns about information-sharing between agencies and training given to support workers.

Ms Hunt said."The inquest heard evidence that support workers need more focussed training on mental health conditions and how to manage and help residents with enduring mental health conditions."