A coroner wants “lessons to be learned” after health professionals made a “number of departures from best practice” when treating a mentally ill woman who went on to fatally stab her GP husband.

Several findings about the care of Marion Hughes before she killed her husband Geraint ‘Tiger’ Hughes in 2013 were highlighted during the second day of his Truro inquest today.

She was voluntarily admitted to hospital on October 17 2013 and released on home leave on November 6 after being prescribed new medication. Marion stabbed her husband in the heart on November 15 and later pleaded guilty to manslaughter with diminished responsibility.

A number of failings were pointed out by expert witness Dr John McKenna although he noted that Dr Hughes’ death was not likely to have been prevented even if best practice was followed.

Dr McKenna gave evidence suggesting that health practitioners should have explicitly enquired about whether Mrs Hughes was taking her newly-prescribed medication when released from the hospital.

He also noted the fact that the care coordinator who was supposed to be supervising Mrs Hughes was not involved in her care at the time of the homicide.

He described how the different failures individually did not cause Dr Hughes’ death, but were part of a “swiss cheese effect”.

He said: “They all have holes in them. Every now and then the holes line up.”

Historic records were unavailable to doctors even though Marion, a former doctor herself, had a history of mental illness going back to 1994.

Dr Ellen Wilkinson, care coordinator of Cornwall Partnership NHS Foundation Trust, said that doctors receiving care were at one point regarded as “VIPs” and their medical records were less accessible than those of other patients.

She added this is no longer the case as the electronic recording system has been updated.

Dr Wilkinson in her evidence stated that there was a care coordinator assigned to Mrs Hughes but they were on sick leave when the patient was released from hospital.

She added that the coordinator had only seen Mrs Hughes four times during her hospital stay in 2013, saying: “That level of contact was probably not as great as we would expect for somebody who had a hospital admission with a severe mental health problem.”

Acting senior coroner Andrew Cox recorded the official cause of death as unlawful killing.

He said: “I want lessons to be learned so we never have to be here in this situation again.

“I think there’s a real opportunity here. I hope in a modest way some good will come out of these tragic events.”

Dr Hughes’ son Mark spoke to the press after the inquest at Truro Magistrates Court this afternoon. 

He said: “While the circumstances are incredibly rare there is a possibility that perhaps some of these changes may help prevent future harm occurring to others.

“That’s the only real thing we can hope from today, there’s nothing that can be done to undo the damage that’s already occurred.”

A spokesperson for Cornwall Partnership NHS Foundation Trust said: “The impact of Dr Hughes’ tragic death was clear at the inquest which concluded today. Our heartfelt condolences and sympathies are with Dr Hughes’ family at this very difficult time.

“After Dr Hughes death, the trust reviewed the care and treatment provided to Marion Williams and made a number of recommendations which have been taken forward. These include strengthening our supervision arrangements and increasing the support we offer to carers.

“We hope the evidence given by the trust’s clinicians will have provided answers for the family.”