A CORONER delivered a damning verdict on a mental health charity who failed to protect a young worker from a psychotic killer.
Ashleigh Ewing died in a frenzied knife attack when she visited the home of paranoid schizophrenic Ronald Dixon in Heaton, Newcastle, in May 2006.
The 22-year-old had been delivering a letter alone informing Dixon he had debts to pay when he flipped and stabbed her 39 times, breaking three blades.
Now, an inquest into the young mental health worker’s death has ruled that there were “major failings” in the management of her employers, charity Mental Health Matters, who run supported accommodation.
The ruling prompted the coroner and Ashleigh’s family to call on the Government to change legislation to protect support workers.
Just months before the attack, deranged Dixon, then 35, was sectioned after stopping his anti-psychotic medication and travelling with his dog to London and making threats to kill the Queen.
But medics at Northumberland, Tyne and Wear NHS Trust deemed he was stable and he was released back into the community and back into the housing of Mental Health Matters.
However, within weeks, the loner again stopped taking his medication, started drinking heavily, had mounting debt problems and trashed a coin-operated phone box in his flat for money.
Despite all this, alarm bells didn’t ring and Mental Health Matters took no action to update an annual risk assessment of the killer, which hadn’t been updated for three years.

It also emerged that crucial information about Dixon had not been passed on from Ashleigh’s line manager Steven Brown to company bosses.
Marie Burdess-Baker, then deputy director and Ashleigh’s team coordinator, said Mr Brown had told her a risk assessment, known as a Q30, had been done.
She told the inquest: “Steve said there was a risk management plan in place and that all staff were aware of it.
“I took him to mean he had completed a Q30. I absolutely trusted his word. I relied on Steve, I know that was not good enough given what has come to light about it being three years since a Q30 was completed.” Ms Burdess-Baker also said she had no idea about Dixon’s violent past, which included a hammer attack on his parents in 1994.
She added: “I didn’t know Mr Dixon had a risk history. I didn’t know about the hammer incident. I didn’t know he had threatened the Queen in London. It was only after Ashleigh’s death I found out he had threatened to kill the Queen. I didn’t know Steve Brown knew that.”
Corner David Mitford said: “I find that startling. That’s significant information you should have known.”
“I absolutely should have, yes”, said Mrs Burdess-Baker.
She also agreed with Mr Mitford that opportunities had been missed and admitted that Mr Brown hadn’t informed her that Dixon had stopped taking his medication for a second time.
Mr Mitford recorded a verdict of unlawful killing, but said failings within Mental Health Matters could have contributed to her death.
He said: “Mental Health Matters lacked their own assessment of the risk Mr Dixon presented and there were shortcomings in their systems that led to a failure in realising the significance of changes to him. In particular, that he’d stopped taking his medication, his paranoid schizophrenic, excessive drinking, his forensic history and his actions in London.”
Returning the verdict, he said: “I’m returning a verdict of unlawful killing to which the inadequacy of the appropriate assessments of risk, its significance and implementation many have contributed.” Mental Health Matters told the inquest they had made a lot of changes in the light of Ashleigh’s death, including making it mandatory for all new workers to undergo 10 training courses and restructuring the management system.
Ashleigh’s cousin Paula Ewing read an emotional tribute to the Northumbria University Psychology graduate.
She said: “It’s heartbreaking that we will never know her true potential professionally and personally but one thing we know is that she wanted to make a difference to people’s lives and I can honestly say she made a difference to ours.
“Not only was she beautiful on the outside, she was also beautiful on the inside. Thank you, Ashleigh.”

Family calls for change in legislation
ASHLEIGH Ewing’s family yesterday called for a change in legislation.
In a statement her auntie, Maureen Binks, said: “On behalf of the family of our beloved Ashleigh, I would like to take time to pay tribute to the impact her short, significant life has had on us and will have on the wider community in the future.
“Ashleigh’s untimely and avoidable death was, in our opinion, due to systematic failings by various agencies in sharing and responding to crucial information, as well as carrying out accurate and timely risk assessments.
“We are truly grateful to the coroner, David Mitford, for agreeing to hold an inquest. We agree with his summing up and verdict and can be more hopeful after listening to the evidence that significant changes have been made.
“We are hopeful that, as a result, other professionals and support workers can carry out their vital roles in the mental health sector.
“We are aware that changes in policy and practice when caring for people in the community are a direct result of the loss of Ashleigh.
“Ashleigh always wanted to be part of a caring profession. She achieved this through her short career but also after her death.
“The inquest has demonstrated that systems are reliant on individual corporate policies and practices, but it is clear that mandatory policies and practices need to be enforced nationally.
“We call upon the Secretary of State for Health and, indeed, the Prime Minister to look at all aspects of care in the community for vulnerable people, especially those with mental health problems, and reconsider current legislation in light of Ashleigh’s case.”
Regret at failings
MENTAL Health Matters yesterday issued a statement to highlight that changes had been made in light of failings on their behalf in caring for Ashleigh.
Helen Mackay, chief executive officer, said: “We offer our sincere sympathies to the family of Ashleigh Ewing at the conclusion of what has been a thorough investigation into the circumstances of her death.
“We have learned important lessons as a result of the events of May 19, 2006.
“The coroner has been rightly critical of the management of the service in which Ashleigh worked and we acknowledge that mistakes were made. The service manager is no longer employed by Mental Health Matters.
“The tragic death of Ashleigh has affected us all and we will live with this forever. We deeply regret the failings that have been identified.
“Our practices and controls have been completely reviewed and revised and we continue our vital and much-needed work in supporting 1,500 people every day who live in the community with mental health needs.”