Inquest into the death Sally Poynton stabbed by her son

Sally Poynton, aged 44, was killed by her eldest son Jacob Poynton-Whiting on June 22, 2021 at her home in Crowlas near Penzance. Her other son and Jacob’s younger brother Elijah, was also stabbed and badly injured as he tried to protect her.

In his summing up of an earlier six day inquest in Truro today, West Cornwall Coroner Andrew Cox said what compounded the tragedy was that it was her son Jacob who was her assailant when Sally had known he was unwell for some considerable time and had been trying to obtain help for him.

He found that had referrals for medical re-assessment of Jacob been accepted or a needs assessment conducted, on the evidence, it is more likely than not Jacob’s deteriorating mental health would have been identified, a treatment plan instituted, and Sally would not have died when she did.

He said at Jacob’s subsequent criminal trial, he was diagnosed by two psychiatrists with schizophrenia. He was charged with murder but, given his diagnosis, the Crown accepted a plea of guilty to manslaughter on the grounds of diminished responsibility.

Jacob Poynton-Whiting

The inquest heard that, following proper treatment, his condition had markedly improved.

The inquest heard that Jacob’s mental health difficulties were well known and a year before Sally’s death in June 2020 he had been detained under s2 of the Mental Health Act and spent ten days or so as an in-patient at Longreach Hospital, run by Cornwall Partnership Foundation Trust (CPFT).

After his discharge, Jacob was recognised by various members of his family, particularly Sally, to deteriorate still further.

He believed he could live for decades without eating and would gain nutrients from the sun and only drank distilled water. He also became electively mute and sunbathed naked in the driveway.

The inquest heard Sally tried repeatedly to persuade state agencies to help her son with an NHS England report (the Niche report) documenting 23 specific requests to four different agencies from Sally for Jacob to be seen and have his mental health assessed and ten occasions when other family members requested help.

Yet, at the time of her death, Jacob was not under the care of CPFT and had not been assessed by a doctor from the trust for a year. Additionally, there had been four alerts to safeguarding but in the 13 months where Jacob was known to Adult Social Care, no one had actually seen him, face-to-face.

Mr Cox said “The DHR noted that ‘…Sally and Jacob’s grandfather tried numerous times to have Jacob reassessed by mental health services, however systemic barriers prevented them and adult social care from making a referral’.”

Also raised at the inquest was the influence of Sally’s former partner Matthew Whiting on her son following an acrimonious split.

The family’s barrister claimed that the “diet of invective” fed by Mr Whiting to Jacob about Sally lie behind his attack on her including him saying Sally was “evil” and “must die”. But Mr Cox said this fell outside the remit of the inquest.

“[These submissions] suggest there was a risk of violence to Sally yet, on my reading of those submissions, these appear to come from her former partner, not Jacob,” said Mr Cox.

“She had shared, I think with a friend by text, a concern that she may be murdered by Mr Whiting but I have seen nothing that she feared being killed imminently by Jacob. As simple matters of fact, Mr Whiting did not carry out the attack that killed Sally, Jacob did.

“I do not in any way seek to trivialise or underplay the concerns Sally had about Mr Whiting. Yet the test here is a stringent one: a real and immediate risk to her life.

“If Sally felt she was at a real and immediate risk to her life from Mr Whiting, she would have informed the police and/or taken out an injunction.”

However he said he was in no doubt there were individual failings in this case such as the incomplete or inaccurate discharge summary (from Longreach) and lack of a plan or information on how to have Jacob re-assessed in the event of his deterioration; the failure to provide Sally with information about her rights as Nearest Relative; the inaccurate recording of Jacob’s new address within the GP surgery in Penryn; the decision(s) not to refer Jacob for assessment upon the second urgent referral completed by Jacob’s Marazion based GP and the request for advice (treated as a referral by Community Mental Health Team) sent by Dr Deacon from Penryn Surgery (twice) and the acknowledged error in closing a requested Needs assessment in May 2021, were just a handful of examples. “I take care to recognise that these are individual failings, they are not systemic,” he said.

Jacob’s friends said that no one had foreseen what was to transpire as Jacob typically was described as a placid, lovely guy, who was not prone to violence. However his behaviour nearer the killing had left one of his female friends scared of him. His father and step-mother were also completely taken by surprise by what happened.

Reaching a conclusion of unlawful killing Mr Cox praised the bravery of the two police officers, PC Styles and PS Green, who were first on the scene to a report of a knife attack, before back up arrived and went into the house unarmed to see what they could do.

He said he would be writing to the chief constable to commend their bravery.

He said Jacob was admitted to Carbis ward at Longreach Hospital on June 7 and he remained there for ten days until his discharge on June 16.

He was determined not to be suffering from a mental health illness and was discharged without a diagnosis or any plan or follow-up.

Despite many attempts by Sally and other members of the family to have him re-assessed, he was not seen again by a doctor from the mental health trust over the following 12 months. After Sally’s death, Jacob was detained, assessed and diagnosed with schizophrenia.

While he found no fault with what the two GPs at Marazion and then Penryn, after Jacob moved in with his dad in Ponsanooth, did in trying to help Jacob, he did find concerning failings at Longreach Hospital.

The trust apologised and said it was being taken at a most serious level and changes had been made.

Mr Cox said the issue lack of staff at the trust was a concern and was a UK wide issue and something needed to be done to renew efforts to recruit additional staff.

He said he will be writing Prevention of future deaths letter to the Cornwall Partnership Foundation Trust.

Raising the issue of domestic abuse by proxy. He said he had been doing this job for 18 years and this was the first time it had come up as an issue.

“Most practitioners will have not heard of it and there is learning here and it is really, really important that learning is disseminated so I will make sure this happens,” he said.

Finally he offered his condolences to the family saying: “Sally was far too young to die. There are lessons to be learned here and I will do my best to ensure that they are learned.”