The inquest concluded that Richard Laversuch, 63, was unlawfully killed on a low-risk ward at Parklands Hospital on 27 November 2021 after multiple failures by healthcare staff. The coroner called the death "utterly avoidable," and the Hampshire trust has apologised and accepted responsibility. Richard's sisters — both former NHS clinicians — say the case exposes systemic problems in care for people with severe psychosis and are urging more inpatient beds, simpler admission procedures and clearer accountability. The case mirrors concerns raised after the 2023 Nottingham attacks and has prompted promises of further action from the trust and government.
Inquest Finds 'Utterly Avoidable' Death on Mental Health Ward — Sisters Call for Urgent Reform
Richard was diagnosed with schizophrenia while at university and suffered episodes of psychosis [Family photo]
A coronial inquest has concluded that 63-year-old Richard Laversuch was unlawfully killed by 18-year-old Owen Herbert at Parklands Hospital, Basingstoke, on 27 November 2021. The jury identified multiple failures by healthcare staff, and the coroner described the death as "utterly avoidable." The Hampshire and Isle of Wight Healthcare NHS Foundation Trust has apologised and accepted responsibility for shortcomings in Herbert's care.
What the Inquest Found
Evidence presented at Winchester Coroner's Court showed that Herbert was experiencing active psychosis in the days before the killing, including delusions that he was in a game and must "complete a massacre" to avoid being tortured. On 26 November 2021, his parents wrestled weapons from him and told the community mental health team they could no longer keep him at home. Psychiatrists later assessed Herbert as a "high" risk to others and the trust accepted he should have been admitted to the psychiatric intensive care unit (PICU).
Despite that assessment, Herbert was placed on a low-risk ward described in evidence as "unsafe and under-staffed." Within hours he assaulted another patient and then entered Richard's room, climbed onto his bed and strangled him in the early hours of 27 November 2021.
Family Reactions and Calls for Change
Richard's sisters, Bridget Ryan and Cathy Laversuch — both retired NHS clinicians — read the inquest papers, attended hearings and listened to days of evidence. They say the case exposes a system that is "inadequate, misguided and plain wrong" for people with severe psychotic illness.
"They just don't recognise how serious psychotic illness is," Bridget told the BBC.
Both sisters urged that severe psychosis be treated with the same urgency as stroke, heart attack or cancer. They called for more funded inpatient beds, simpler and robust admission procedures (day and night), and less over-reliance on community care and on families to manage crises.
The killing took place on a low-risk ward at Parklands Hospital in Basingstoke [BBC]
Cathy said staff were also let down by a complex system in which responsibility was passed between teams. "It's too easy just to say, 'oh, but that's not my role'," she said. The sisters have agreed to work with the trust to identify improvements.
Outcome for the Perpetrator and Statements From Both Families
Herbert pleaded guilty in 2023 to manslaughter on the grounds of diminished responsibility and is detained indefinitely at Broadmoor Hospital. His parents, David and Rachel Herbert, told the inquest they had believed he would be safe in hospital and expressed "profound regret, sorrow and anger" about the outcome.
Wider Context
Some of the care failings highlighted in this case echo issues raised after the 2023 Nottingham attacks, when Valdo Calocane — who had paranoid schizophrenia — killed three people. An independent NHS England report found repeated missed opportunities to respond to persistent psychosis and escalating risk. The NHS trust responsible for that care is under investigation.
Trust and Government Responses
The Hampshire trust said it has made many changes since Richard's death and apologised to both families. The coroner commended the sisters for their determination to "effect change." The Department of Health and Social Care said there is "more to do" and pledged to set out later in the year how its mental health strategy will respond earlier and reduce waiting times for support.
Key dates and facts: Richard Laversuch was killed on 27 November 2021; Owen Herbert pleaded guilty to manslaughter in 2023 and is detained at Broadmoor.
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