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Published 19 January 2022
By Phil Shepka
SSRIStories Summary: Teen, 19, diagnosed with schizophrenia, drugged for 16 years with “antipsychotics” and antidepressants predictably has erratic moods, poor self control. By age 36 he has GI problems with pain, and is on 13 medications. His sertraline dose [this drug has a known side effect of violent thoughts], is increased in May 2019. A few months after this. he threatens to kill 2 people, staff do not take him seriously. He carries out threat to kill one person and is charged with murder. Meds never considered a contributor, not mentioned in news articles.
Katy Sprague was described by her family as “kind, considerate, loving and loyal”
A woman was not told her neighbour had threatened to kill her just hours before he murdered her, a review has found.
Zac Jackson strangled Katy Sprague, 51, at a supported living complex they both lived at in Cambridge in November 2019.
A review found failures were made in Jackson’s care and Ms Sprague was not “adequately safeguarded”.
Cambridgeshire County Council said it would work with partners to ensure the findings were “fully implemented”.
A spokesperson said the authority had taken a “thorough review of how we commission and contract in this area of adult social care” since the murder.
Jackson strangled Ms Sprague, his neighbour at Denham Place, in the common room of the flats on Coleridge Road – where support for people with mental health difficulties is run by Sanctuary Supported Living – on 27 November 2019.
He was convicted of murder last year and jailed for a minimum of 15 years.
The family piecing together an ‘avoidable murder’
Zac Jackson had threatened to kill Ms Sprague the year before the murder.
The court heard that on the morning of the murder, Jackson attempted to strangle a community psychiatric nurse, later saying he was “going to kill her, kill the manager and kill Katy”.
A safeguarding adults review, published on Wednesday, found there had been tensions between Ms Sprague and Jackson in the past and “this was not referred to when the threats, just prior to her death were made”.
Ms Sprague “was not made aware of the threat that was made about her some hours before her death and there was not enough consideration regarding her safety”, the review found.
The review also found similarities “in many ways” with a previous incident in November 2018, when Jackson made a gesture as if to strangle a support worker and made threats to kill others, including Ms Sprague.
Coleridge Road, Cambridge
Image caption, Sanctuary Supported Living provides the support at the flats on Coleridge Road,
It said there had been “continual evidence of self-neglect” by Jackson but found “a lack of evidence that there was any coordinated activity to address this with consideration to [his] mental capacity and mental health”.
The report continued: “It has to be concluded that there were indications that [Jackson’s] mental health and physical health were declining and there were indications that he posed a risk.
“He had on at least one occasion made specific threats regarding [Ms Sprague]. The care and risk plans did not adequately reflect or mitigate this.”
It questioned whether Jackson, who according to the report had paranoid schizophrenia, would have been better in accommodation with a “more detailed care and support plan”.
An inquiry by Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) previously found Ms Sprague was “not effectively safeguarded”.
Image caption, Jackson must serve a minimum of 15 years in prison for Ms Sprague’s murder
The review found the nurse, referred to in the report as a care coordinator, said she did not inform other staff of Jackson’s threat, “because she was in shock and briefly forgot about it”.
But it added she did not perceive Jackson to be a threat to her, the support worker or Ms Sprague, adding: “Rather Jackson’s concerns were about himself, and his actions were seen as largely a way of getting attention.”
An Independent Investigation Into the Care and Treatment of Mr D – Niche Health and Care Consulting
1.5 Mr D  had a diagnosis of paranoid schizophrenia and recurrent depressive disorder. He was a recipient of mental health services provided by Cambridgeshire and Peterborough NHS Foundation Trust (‘the Trust’). Mr D had used Trust services since he was 19 years old and had been detained under the Mental Health Act3 (MHA) in the past. His last inpatient admission, a month long, ended in January 2017.
1.6 Mr D had a private flat in supported living accommodation managed by Sanctuary Supported Living (‘Sanctuary’). He held an assured tenancy which meant his residency was not dependent on engaging with Sanctuary’s services. Mr D had a care package of low-level services e.g., being taken to medical appointments and reminded to take his medication.
1.7 Mr D was under the Trust’s Care Programme Approach (CPA) and had an allocated Care Coordinator. He was seen every two weeks by his Care Coordinator, who administered his depot medication and checked on his general wellbeing.
1.8 Mr D had several physical health problems, predominantly related to his stomach and he experienced significant stomach pain. Medical tests indicated Mr D had gastritis and Barrett’s oesophagus which could be managed by medication and diet, but Mr D did not always take his medication or eat healthily.
1.16 Consultant 1 reviewed Mr D on 21 November 2018. He told her that “voices” were telling him not to eat.
1.18 Mr D continued to report stomach pain throughout 2019 and was regularly advised by his GP practice, Sanctuary and Trust staff to manage his diet.
1.19 Mr D’s Consultant noted during his CPA review in May 2019 that he was “at a very poor level of mental health”. The Consultant noted that Mr D remained at risk of deterioration which in turn would negatively impact his physical health self-care. Mr D agreed to a trial of increased sertraline dosage.
1.22 Mr D’s Care Coordinator saw him on 27 November 2019 to administer his depot medication. Mr D was lying on his sofa, shaking. He told his Care Coordinator “I need sectioning”. The Care Coordinator asked if this was because of his physical pain, which Mr D confirmed. Mr D then sat up and placed his hands around his Care Coordinator’s neck. The Care Coordinator used breakaway 6 techniques to extricate herself and left the flat
1.23 Mr D followed his Care Coordinator who had found a member of Sanctuary staff. They agreed with Mr D they should all attend the staff office with a view to discussing what had happened. Mr D asked for a hospital admission, saying he needed to be sectioned. He said he would kill the Care Coordinator, Sanctuary staff worker, and Miss Y, another resident who was not present.
1.26 The CRHTT and locality Consultant were not informed that Mr D had made a specific threat to kill the staff or Miss Y.
1.27 Mr D’s Care Coordinator returned to Mr D’s accommodation to tell him the CRHTT would attend the next day. Mr D was noted to be happy with this plan and apologised for his earlier behaviour. He told his Care Coordinator he could keep himself and others safe. He was advised to call the emergency services or 111 if he began to feel unwell, after which the Care Coordinator left.
1.28 Mr D committed the homicide shortly after his Care Coordinator left on 27 November 2019.
4.174 Mr D’s medication documented at his CPA review in May 2019 was:
- Flupentixol decanoate [so-called antipsychotic]
- Sertraline [SSRI antidepressant]
- Pregabalin [painkiller]
- Mirtazapine [antidepressant]
- Mebeverine [alleviates irritable bowel syndrome]
- Docusate [stool softener]
- Colecalciferol [D vitamin]
- Qvar (beclomethasone) [asthma inhalant]
- Salbutamol [inhalant]
- Prucalopride [for chronic constipation]
- Lansoprazole [for heartburn]
- Ranitidine [for acid indigestion]
- Fortisip [nutritional supplement]