A coroner has identified 'missed opportunities' that could have potentially prevented the murder of an 80-year-old woman by her schizophrenic grandson. Subell Ali, 34, stabbed his grandmother Somtera Bibi more than 20 times at his mother's home in Manor Park, East London, on April 2, 2022. Ali has been detained indefinitely at a secure hospital since March 30, 2023.
Release from psychiatric care
Ali, from North London, had been released from a mental hospital just two days before the attack. He was first detained in May 2020 after telling police he was hearing voices instructing him to 'stab people'. He was eventually discharged from a psychiatric hospital on March 31, 2022. A court heard in March 2023 that Ali's mother heard the attack and found Ms Bibi in the living room. Ali was arrested 10 minutes later at a bus stop, covered in his grandmother's blood.
Coroner's concerns
Local coroner Nadia Persaud raised concerns regarding East London Foundation NHS Trust, stating in a prevention of future deaths report that there were 'missed opportunities' to safeguard Ali's family upon his release. Despite Ali making threats of domestic abuse, sexual abuse, possession of weapons, and threats to kill family members while unwell, no safeguarding measures were implemented for his family. The coroner also noted that despite Ali's conviction for knife possession and threatening behaviour over many years, there was no prevention plan, family safety plan, or significant attempt to protect the family.
Missed opportunities identified
The coroner acknowledged that even with a suitable risk management plan, Mrs Bibi's death might not have been prevented, but emphasized a 'missed opportunity to attempt to safeguard her'. The first missed opportunity was the lack of response to police attempts to create a safety plan for Ali's family, leading to a trust-wide communication clarifying expectations for contacting police. After an assault on his mother in 2020, no advice was sought from the forensic psychiatric team despite his previous conviction; the trust has since ensured referrals can be made directly to a forensic colleague via their secretary. The third concern was addressed by requiring all staff to complete safeguarding training and issuing a newsletter identifying DASH risk assessments as a learning point.
Trust response and improvements
Since the incident, the trust has collaborated with Local Authority workers through joint forums and regular meetings for mental health services to improve safeguarding. Additionally, East London NHS Foundation Trust said they would focus on risk assessments in homes, such as identifying risks to the family and mitigating them in the short term while awaiting court approval to section a person, including temporarily locking away sharp objects.
A spokesman for the trust said: 'Our deepest sympathies are with the family and friends of Somtera Bibi. Following this tragic incident, work has been undertaken to take learnings from the coroner's findings. This includes more robust focus on our safeguarding processes and supervision, as well as risk assessment and management. We remain committed to learning from shortcomings and addressing them.'
