THE family of a mother who was stabbed and killed by her son in the kitchen of her home have called for “systemic change” following what they described as an “avoidable tragedy”.
The comments by Dr Patric Nisbet and other members of his family came at the conclusion of an inquest into the death of his wife, Pam, which highlighted serious failures in the care and treatment of their son Andrew, who killed his mother on 6 August 2019.
Viscount Mark Harris, presiding over the inquest as coroner, was especially critical of social worker Lisa Chapman, who was the authorising officer for a mental-health assessment of Nisbet that took place on 1 August but disagreed with two clinicians about whether he should be detained.
The coroner observed: “Had Miss Chapman acted as she should have done and made the application for admission under the mental-health law it is probable that Andrew would have been admitted to hospital before he killed his mother.”
Nisbet, who was aged 40 at the time of the attack and had been diagnosed with severe autism spectrum disorder and Asperger syndrome, pleaded guilty to manslaughter on the grounds of diminished responsibility when he appeared at the Royal Court in June 2020. Two months later he was sentenced to remain in a secure psychiatric hospital.
Advocate Harris said inadequate steps had been taken to assess and address Nisbet’s condition over an 18-month period, towards the end of which – the inquest heard – police officers were called on three occasions to the Nisbet family home in St Peter.
Nisbet had been living in a pool house property at the home with his partner and young child since returning to Jersey in late 2017 and had repeatedly clashed with his parents over whether he could remain living there, with his mother and father seeking to persuade him to move to a three-bedroom house they had purchased nearby.
Advocate Harris spelled out a number of serious failings by Miss Chapman, including an inadequate review of the case before assessing Nisbet, not talking to his mother when she had the chance and dismissing the concerns of two doctors familiar with the case.
Her delay in taking action after reviewing the case further on 2 and 5 August and belatedly absorbing “concerning and alarming” information in the case notes were also highlighted.
In a statement issued by a lawyer representing them, Mrs Nisbet’s family said: “This was an avoidable family tragedy – we hope there will be systemic change in the future.
“Pam died as she lived, fearlessly going into harm’s way to help someone that she loved. She is sorely missed.”
The family thanked those involved in the inquest for a “thorough and diligent inquiry” and paid tributes to the “exemplary” work of Dr David Bailey, the family doctor, and to the States police for the force’s “exceptional skill and care”.
Advocate Harris said that he had been reassured by the evidence of Andy Weir, director of mental-health services, about changes to policies and procedures introduced over the past two years. He said he was satisfied that this action meant he did not need to make specific recommendations in order to prevent future deaths.
The inquest had heard that Nisbet had previously attempted suicide on two occasions, the second by jumping from a second-floor window in January 2018 after his father turned down a request to install a heat pump in the property.
The long-running row with the family worsened over the next 18 months, culminating in Nisbet stabbing his 68-year-old mother with a “Leatherman” knife before being wrestled aside by his father in an unsuccessful attempt to save his wife’s life.
