Inquest Findings Put Custody Mental Health Assessment Under Sharp Scrutiny
Police and health leaders in Devon are now under pressure to absorb the lessons of a fatal chain of decisions that preceded the killings of two elderly brothers and another elderly man in Exeter. The inquest into the deaths of Anthony Payne, Dick Carter and Roger Carter concluded that failures across agencies contributed to the attacks carried out by Alexander Lewis-Ranwell, who had been in police contact shortly before the killings and was known to be acutely unwell.
The central concern is not simply that a dangerous man was released. It is that the systems meant to identify severe mental illness in custody did not work when they mattered most.
Lewis-Ranwell was arrested twice in the two days before the killings. During the inquest, one police officer described him as “one of the most mentally unwell individuals I can remember encountering,” a remark that captures how obvious his distress appears to have been to those who met him. The jury then criticised the failure to carry out a mental health assessment and the failure of police to understand their powers to detain him under the Mental Health Act.
Custody Decisions, Mental Illness and the Cost of Delay
The deaths unfolded in 2019 in Exeter, Devon, after Lewis-Ranwell attacked the elderly men in their homes. The two Carter brothers, twins and retired mushroom farmers, were killed in the family setting where they should have been safest. Payne had returned home to feed his cat when he was attacked. Those details matter because they show how quickly a custody error can become a community tragedy when a patient with psychosis moves back into the public realm without proper assessment.
Psychosis can distort judgment, amplify persecutory beliefs and drive unpredictable behaviour. In custody, that psychiatric risk is compounded by exhaustion, fear and the fragmented nature of short police encounters. A detainee may appear verbally coherent at one moment and profoundly disorganised the next, which is exactly why timely clinical review is designed to interrupt the pathway from illness to harm.
The inquest jury said there were failures by agencies at multiple points. It also found systemic failures involving Devon County Council and Devon Partnership Trust in relation to the policies and practices used to refer detainees for mental health act assessments. In practical terms, those findings point to a broken chain: recognition of illness, referral for assessment, decision-making authority and documentation all have to line up, and here they did not.
Police, Council and NHS Leaders Accept the Jury’s Conclusions
Devon and Cornwall Police Assistant Chief Constable Nikki Leaper said the force was addressing “areas of learning and change” and accepted the jury’s findings. She said the force continued to make every possible effort to ensure the security and safety of people admitted into police custody, including during detention and release. Her comments reflect the difficult reality of frontline policing: custody staff are often the first and last professionals to see someone whose mental state is deteriorating, yet they are not always equipped with the clinical pathway needed to make safe decisions.
A spokesperson for Devon Partnership NHS Trust said the organisation would reflect on the jury’s conclusions and remained committed to continuous learning so that improvements are embedded in systems and practice. That language signals a familiar but critical challenge in mental health care: lessons are often identified after a death, while the patient pathway itself depends on systems that should already be functioning.
One sentence from the inquest stands out because it captures the level of concern inside the custody process. Lewis-Ranwell was already viewed as severely unwell, yet the required assessment still did not happen. In a mental health crisis, a missed assessment is not an administrative slip; it is a clinical failure with immediate safety consequences.
Family Demands Lasting Change Across the System
The Carter family has called for “meaningful, lasting changes across all the organisations involved” and has urged a national review of guidance and training on mental health issues in police custody. Their demand is broader than one case. It speaks to the recurring problem of how severe mental illness is handled when police, council services and NHS providers all hold part of the responsibility but no single person owns the whole risk.
The family’s position is also shaped by the pattern of events that preceded the killings. Lewis-Ranwell had been arrested twice in a short period, his behaviour had already alarmed officers, and the jury later found that the relevant agencies failed to join up their responsibilities. In mental health care, fragmented oversight can be catastrophic because risk is dynamic. A person who appears manageable in one encounter may become dangerous within hours if psychosis is left untreated and no one takes ownership of escalation.
Policy Changes and the Limits of Post-Death Learning
Devon County Council said it had acted on a review after the deaths and that the inquest had reporting additional learning. The council said it had briefed approved mental health practitioners and strengthened guidance around referrals, decision-making and record-keeping. It also said a wider review would strengthen management oversight, audit and learning to support more consistent practice.
Those are the kinds of operational changes that can matter at the bedside and in the custody suite. Better referral guidance can reduce uncertainty over who should trigger a Mental Health Act assessment. Stronger record-keeping can make it harder for warning signs to vanish between services. Oversight and audit can expose whether staff are actually using the pathway in real cases, rather than merely knowing it exists on paper.
The council also said a negligence claim brought by Lewis-Ranwell against public authorities in Devon, including the county council, was struck out before the Supreme Court.
The case leaves a narrow but urgent set of clinical questions behind. How reliably are custody staff trained to recognise psychosis? How quickly can detained individuals be assessed when their behaviour is alarming but their legal status is uncertain? And how often do communication failures between police, council and NHS teams allow a person in mental health crisis to pass back into the community without the intervention that might have prevented violence?