A six-day inquest in Leeds heard how 53-year-old Mrs Regan and her family had tried in vain to help grandson Rakeim Regan, also known as Rusty, deal with his failing mental health as he plunged into a paranoid crisis.
But an absence of on-call specialist doctors meant he was never seen by a psychiatrist and the correct course of treatment implemented.
Mrs Regan was found dead in her Leeds flat at Marlborough Grange on June 1, 2008, after Rakeim stabbed her in the head and neck, believing she was conspiring against him and talking with police.
Procedures to admit mental health patients have already been changed in Leeds, following the tragedy.
Family GP Dr David Watson had referred Rakeim as a priority case to the Crisis Resolution Team at the Becklin Centre in Leeds owing to the 20-year-old’s increasingly bizarre behaviour.
Mrs Regan and uncle Anthony Johnson took him in desperation to the A&E department at St James’s Hospital, where he was assessed by nurse Tim Chippindale. He issued a sleeping tablet and advised he went home with his grandmother, saying staff would assess him at home the following morning.
The family claims they had wanted Rakeim to be sectioned and treated in hospital, but say they were informed there were no mental health beds available.
Hours later he stabbed his grandmother, a leading campaigner for Mothers Against Violence.
The inquest was told how Rakeim had smoked cannabis from the age of 13. He had also been devastated by the violent death of his uncle Danny in 2002.
West Yorkshire Coroner David Hinchliff, issuing a narrative verdict yesterday at Leeds Coroners Court, said: “Rakeim’s mental health was deteriorating further and his paranoia increasing.
“An assessment by a specialist registrar psychiatrist could have produced a differential diagnosis of paranoid schizophrenia. Then Rakeim could have been removed from his grandmother’s home. The outcome of which is that Pat would not have been unlawfully killed by stab wounds.
“Rakeim was seriously mentally ill. The failure by those involved to have him assessed by a specialist registrar psychiatrist on two occasions at St James’s Hospital and again at Pat’s home, provides the causal connection with the events which led to the tragic incident.
“This is a double tragedy for the family. Not only have you lost Pat, but you have also at this time lost Rakeim, who is currently in secure treatment. I hope he will recover and secure his place back in the family.”
Shane Fenton, speaking for the family, said afterwards: “It has taken four years but finally we have got to the truth of how Pat and Rakeim were failed by Leeds Mental Health Crisis Team. Had staff given Rakeim the medical help he so desperately needed, Pat would still be alive today. We hope lessons have been learnt so no other family has to go through what we have been through.”
Chris Butler, chief executive of the Leeds and York Partnership NHS Foundation Trust, said: “I’d like to extend our deepest sympathy to everyone affected by this tragic incident. It is always our aim to provide safe and reliable services. The assessment of Rakeim Regan in 2008 was carried out with the best of intentions by a single practitioner in order to provide a rapid response to an urgent situation.
“We fully accept the Coroner’s findings regarding the absence of on-call specialist doctors during the Trust’s interaction with Rakeim. We are committed to improving our services and have already changed our policy and procedures.”