On the fourth anniversary of the stabbing to death of a Jewish klezmer violinist outside a kosher bakery, his family have expressed their dismay at delays to an inquest to discover what led to the tragedy.
Father-of-three Michael Kahan, 39, was attacked by paranoid schizophrenic Jonathan Mills in June 2008 outside the State Fayre kosher bakery in Crumpsall, north Manchester. Mr Kahan’s son, Max, who was 13 at the time, waited for his father on a nearby street corner with a box of chocolates for Michael’s upcoming 40th birthday. But his father never arrived.
An inquest was opened and adjourned immediately after the death by the Manchester coroner, Nigel Meadows, when it emerged that Mills had been released by officials at Pennine Care Mental Health Trust just 10 days before he attacked Mr Kahan. He had been suffering from delusions that Jewish people were preventing him from getting his medication, and later said he had intended to kill a Jewish person that Sunday morning.
In December 2008, Mills pleaded guilty to manslaughter and was sentenced to indefinite detention at a high-security psychiatric hospital.
But four years after the stabbing, the resumed inquest, to establish why Mills was released by health officials and to prevent similar incidents recurring, has still not taken place. Since Mr Kahan’s death, there have been 31 other mental health-related killings in the North West.
A family member, who asked not to be named, told the JC that it was “worrying” that no inquest had occurred.
“Everybody in the family has been upset by the extraordinary length of time to establish what happened.
“It is difficult to know whether the time that has elapsed is in the slightest bit justified. The coroner himself has, I think, done all he could to try to get people to establish the facts as far it is possible,” said the relative, who added his belief that Michael Kahan’s death had been avoidable.
“Various people should have jumped to action but did not. It’s a wound that is reopened quite often,” he said.
The cause for the delay is unclear, although it is partly because Pennine Care was the subject of an independent NHS investigation in 2010 that catalogued a series of failures the Trust made in Mr Kahan’s case.
Such failures included conducting a flawed internal investigation which broke the Trust’s policy and did not interview senior managers responsible for Mr Mills’s care. The NHS report also says Pennine has lost the archival material records it used to conduct its internal investigation.
The North West Strategic Health Authority, which conducted the independent probe, stopped short of holding Pennine Care responsible for Mr Kahan’s death but concluded that the Trust had failed to recognise “significant risk factors” and said family members were “angry that they had received no communication for a period of years”. An inquest may rule differently.
The Kahan investigation was among 15 other similar deaths probed by the NWSHA, over concerns that internal investigations by a number of NHS trusts in the North West were not conducted properly, a process concluded in January 2011. Yet no date for the inquest into what happened in the Kahan case has been set, despite this procedure concluding.
Henry Ticehurst, medical director at Pennine Care NHS Foundation Trust, said: “First and foremost, we apologise to the family of Mr Kahan and for the failings identified as part of the review.
“Following this incident four years ago, the Trust has implemented a number of improvements and strengthened its governance arrangements to ensure patient safety is paramount. Incidents of this nature are a rare occurrence and we place great importance on providing safe and effective services for our patients, their families and carers, as well as the wider public.”