Care failings before woman dismembered in her home, safeguarding review finds

Multiple failings have been identified in the case of a woman who was killed and dismembered in her own home. 

Luke Deeley, 26, who had earlier been diagnosed with psychosis and was living rough, walked into June Fox-Roberts' home in Pontypridd, Rhondda Cynon Taf, in the early hours through an unlocked door and killed her in November 2021.

It is thought Ms Fox-Roberts came downstairs and was attacked by Deeley in the hallway.

She suffered head injuries before being dragged into the dining room where she was placed on a tarpaulin, decapitated and dismembered using an axe.

Ms Fox-Roberts’ body was discovered on 21 November by her daughter Abi Sheppard, who dialled 999, and a family friend, who had become concerned after being unable to contact her.

Deeley, then 25 and an art student, was arrested two days later after being spotted on CCTV living rough at a nearby tyre depot.

A safeguarding review has concluded that opportunities were missed and made several recommendations which were accepted by Cwm Taf Morgannwg health board which apologised.

At his subsequent sentencing, the court was told that Deeley, who admitted manslaughter on the grounds of diminished responsibility, had been diagnosed with paranoid schizophrenia. He was detained indefinitely at Ashworth psychiatric hospital in April 2023.

The safeguarding review report criticised agencies for not sharing information about Deeley having "strange thoughts about women" or that they found pictures of naked women tied up with ropes in his student bedroom.

It said, while no one could have predicted what would happen, "all of the information pointed to someone who was experiencing a significant and insidious deterioration in their mental state", and who was also expressing, "unusual beliefs about, and acts of aggression towards, women."

A single unified safeguarding review was carried out to assess the role of agencies involved in the case, including the health board, Rhondda Cynon Taf council, South Wales Police and the University of South Wales.

The review found that there was poor communication between all agencies including education, health, local authority and police and between these agencies and the Deeley family.

It also said that there were “missed opportunities" in Deeley's care involving the Community Mental Health Team and that there was no mechanism for sharing information when a patient moved between health board localities on a temporary basis, as Deeley did as a student.

The review added that South Wales Police should have categorised the killing as a "critical incident" and the rationale for not doing so was unclear.

The safeguarding report follows a series of cases where the role of authorities has been criticised when caring for people with serious mental illness who have gone on to kill.

Cwm Taf Morgannwg health board was also criticised after the killing of John Rees, 88, in a Co-op store by Zara Radcliffe in May 2020.

An inquest in May 2024 also found serious failures by the authorities contributed to the death of Dr Kim Harrison, who was killed by his son.

Ms Fox-Roberts, a former IT consultant who loved baking and ran a cafe for a time, was described by her family as "a force of nature, passionate, vibrant, determined."

Abi Sheppard said her mum's killing "destroyed my world" and that she was angry that the system "has let us down."

She added: "He had a history of violence and aggression. And if he’d been cared for properly and monitored, would it have happened? We’ll never know. It’s not good enough that people are falling through the cracks. There are consequences to that. My mother is one of those consequences and it’s destroyed my world because he wasn’t cared for properly."

Ms Sheppard said that, while the report had answered some of the family's questions, others remained, including "why that house, why that street, why the way he did it, why he dismembered her?"

In a statement, Deeley's parents said the health board "failed to provide the care and support needed by our son" and said, if it had, "this tragedy may have been prevented."

They added: "There have been too many mental health-related tragedies in this health board area. Due to a lack of accountability and failure to implement the lessons learned from previous reports, the same mistakes are needlessly being made time and time again.

"We cannot imagine the devastation caused to the family of June Fox-Roberts and they are always in our thoughts."

Health board chief executive, Paul Mears, expressed his "deepest sympathies" to Ms Fox-Roberts' family and said the review recommendations reflected the findings of its own internal investigation. He said: "We apologise to both families for the instances in which Luke Deeley's care fell short of the high standards we expect for all of our service users."

A spokesperson for Rhondda Cynon Taf council said: "We will work with our partners to ensure the recommendations are fully implemented and commit to learning lessons from this tragic incident.”

Chief executive of mental health charity Adferiad, Alun Thomas, said the report identified some issues in common with other cases, including lack of communication with patients’ families and carers, and lack of coordination and joined up working between services.

It was clear that Luke Deeley had “slipped straight through the net” and that his family were “left adrift” with their concerns.

He said: “It’s very, very disappointing when we’ve heard about lessons being learnt in the past, that they don’t appear to have been learned on this occasion.”

He echoed calls in the report for Welsh government to commission a thematic review of learning points from reviews of four mental health homicides in the Cwm Taf Morgannwg area between 2018 and 2021.