Susan Gray killing: Police feared paranoid schizophrenic son had gun A YEAR before he shot his mother dead

Police had 'low level' intelligence that 22-year-old Joseph Gray had a hand gun in October 2010 but it was ruled there was 'insufficient' evidence to act despite his extensive criminal history.

Child minder Susan Gray, aged 49, was shot in the face by her son at her Stafford home a year later.

Mrs Gray had also told mental health nurses of her son's 'fascination' with knives but nothing was done.

Police had also stopped Gray for carrying knives and for owning a dangerous dog.

• There was a significant failure to jointly evaluate concerns about Joseph in March 2011 by police and mental health services.

• Police and the health services record sporadic consultation about Joseph's activities but it is not clear what each agency intended in terms of actions to resolve the problems presented by mental health concerns and criminal activity.

• Opportunities to action in respect Mrs Gray's 14-year-old daughter, and the children she looked after as a child minder, were missed and action in one area did not routinely result in a review of the other.

• Communication failures meant the seriousness of the risks were not shared.

• The Probation Service, could have made more rigorous checks on the family and the risks to Mrs Gray and her daughter from her son.[/breakout]

A Domestic Homicide Review has found there was a 'significant failure' by police and the mental health service to share information they had on the troubled man.

The review, the first of its kind in Staffordshire, found numerous missed opportunities between Staffordshire Police, Staffordshire County Council, Ofsted, the Probation Service, and most prominently the NHS, to share and act on information they had on the gunman.

The report said: "Joseph was found inappropriately in possession of knives both at home by his mother and when out by police, and described by his mother as having a fascination for them.

"He had a dog that was perceived as dangerous, as well as there being low level intelligence reports in October 2010 that he acquired a hand gun but that was never confirmed.

"The intelligence was reviewed by senior officers at the time and it was considered that there was insufficient basis for action.

"None of the professionals responsible for decisions in respect of Joseph had the complete picture and health professionals were working from his and his mother's information rather than the wider picture known to the police."

It added: "The South Staffordshire and Shropshire Healthcare NHS Foundation Trust's Individual Management Review does not comment on the responsibility of mental health services to prevent crime and reduce risks to others but it cannot be in the best interests of patients to so ignore such matters that very serious crimes are subsequently committed by them.

"Neither the mental health services nor the criminal justice system engaged effectively with each other about Joseph to contain or restrain his behaviour. His engagement in serious crime was known by criminal justice services and he presented a very considerable threat to the wider community through the supply of illegal substances and the associated criminal activity. Both agencies failed Joseph, Susan, his sister, and the wider community in failing to use the powers available effectively to share information and agree joint action. Instead both agencies watched and waited and failed to evaluate the accumulating evidence of risk to others."

Mrs Gray's body was found slumped at the bottom of the stairs at her Oxford Gardens home on the morning of October 27, 2011. A neighbour, who had a spare key, made the discovery after parents due to drop their children off at the house found there was no response.

Joseph is now being detained in a clinic after admitting manslaughter at Stoke-on-Trent Crown Court this year. He had previously been ruled unfit for trial.

The review found Gray had a history of mental illness and a prolific criminal record – including drug use and dealing.

He had also been admitted to hospital detained under the Mental Health Act on three occasions in 2011 – the year of the shooting.

Concerns over the welfare of Mrs Gray's daughter and the children she looked after as a child minder was expressed by the review panel.

The report concluded that the agencies had not considered that Joseph could kill.

The report said: "The panel believe that it was predictable that something untoward was likely to happen to someone, somewhere, sometime unless the situation was contained or disrupted. However what might happen, when and where it might happen and who might be hurt was quite uncertain. That it would result in the death of anyone, let alone the murder of Susan by her son was not something anyone had considered a possibility."

Assistant Chief Constable Jon Drake said: "We accept the findings and recommendations of this review and our thoughts remain with the family and friends of those it concerns.

"We, along with our partners, recognise that lessons have been learned and changes implemented as a result of the death which occurred.

"Now more than ever we are working hard to share relevant information with partners to ensure the most vulnerable in our communities are protected, and they are receiving the right help and support they need.

"A key development to ensure better information sharing was the launch of the Multi-Agency Safeguarding Hub (MASH) in December 2011. This has significantly enhanced information sharing amongst agencies.

"The MASH involves Adult and Children Services for Staffordshire and Stoke-on-Trent sitting together with the police. The MASH provides quick time information sharing between partners to identify an accurate level of risk in order that an informed decision can be made as to which agency/department is best to deal with the problem.

"The appropriate interventions can then be put in place.

"We are continually reviewing our procedures to ensure we are delivering the best service possible to the communities we serve."

A South Staffordshire and Shropshire NHS Foundation Trust spokesman said:

"This was a tragedy and our thoughts are with the family as this report is published. We are committed to learning any lessons from any serious incidents and indeed a comprehensive action plan was developed following this review to address the key issues.

"In particular we have improved the way we support carers and are now a member of the national best practice Triangle of Care scheme. This recognises that carers are often the only constant in the service users mental health journey and must be an integral part of the care package.

"In addition all clinical teams now have enhanced training on engagement, support and information sharing with carers.

"We are committed to work better to share information with partners and always look to improve the care and support of vulnerable people and their families/carers, to this end we are part of the Multi-Agency Safeguarding Hub (MASH), launched in December 2011. This has significantly enhanced information sharing amongst agencies."

Mike Lawrence, Staffordshire County Council's cabinet member for Children and Community safety, said: "This is distressing case and the review is a valuable way of ensuring we understand what happened and take steps to ensure we act on any lessons learned.

"While the review found that our involvement was proportionate and it was not likely the tragic events could have been prevented, it emphasises the huge importance of partners working together to help keep Staffordshire residents safe.