'Systemic Failures and Missed Opportunities': Pensioners Killed Hours After Their Attacker Was Freed

An inquest jury has found that a series of 'systemic failures' by police, healthcare services and a private contractor probably contributed to the deaths of three Exeter pensioners killed by Alexander Lewis‑Ranwell within hours of his release from custody in February 2019.

Anthony Payne, 80, and identical twins Dick and Roger Carter, 84, were killed on 10 February 2019 after Lewis‑Ranwell, now 35, walked out of Barnstaple police station.

The jury criticised Devon and Cornwall Police, healthcare professionals employed by Devon County Council and Devon Partnership Trust, and contractor G4S. In its conclusions, issued on Tuesday, it said the shortcomings 'probably made a more than minimal contribution to the three deaths'.

Lewis‑Ranwell had already been arrested twice in the days before the killings. He was first detained on 8 February, then arrested again on 9 February after attacking elderly farmer John Ellis with a saw.

While in custody after the second arrest, he was assessed by Dr Mihail Pichiu, a force medical examiner employed by G4S. Dr Pichiu did not recommend an assessment under the Mental Health Act, although he asked for Lewis‑Ranwell to be seen by a mental health nurse the following morning. That appointment never took place.

Lewis‑Ranwell was released and travelled from Barnstaple to Exeter. There, he attacked Anthony Payne with a hammer and killed the Carter twins with a shovel.

Jury Lays Bare 'Broad Shortcomings'

The inquest heard that concerns about Lewis‑Ranwell's mental health had been raised repeatedly before the killings. His mother, Jill Lewis‑Ranwell, spoke to an officer after his second release and was told her son was 'crazy'.

The jury found Devon and Cornwall Police had 'broad shortcomings in information gathering, sharing and recording'. It said the failure to record his mother's call was a serious failing that probably made a more than minimal contribution to the deaths.

Jurors also identified an over‑reliance on verbal rather than written handovers, a failure to check details on the Police National Computer, and a failure to pursue Lewis‑Ranwell's mental health records.

They further found officers misunderstood Section 136 of the Mental Health Act, which allows police to detain someone who appears to have a mental disorder and needs immediate care.

The jury concluded there were systemic failures at Devon County Council and Devon Partnership Trust concerning referrals for Mental Health Act assessments. It also found Dr Pichiu had a 'fundamental misunderstanding' of how to conduct a mental state examination, dismissing signs of delusion and disordered thinking.

G4S was criticised over Dr Pichiu's recruitment. The jury found there was significant evidence of a complete disregard by the company for its own policies, and therefore for patient safety.

Families Demand Lasting Change

The Carter family said the inquests had exposed the failures that cost Dick and Roger their lives. Their niece, Amanda Taylor, said: 'Nearly eight years after the brutal killings of our uncles, Dick and Roger Carter, we finally feel that the inquests have exposed the systemic failures and missed opportunities that cost them their lives.'

She added that the family hoped the findings would lead to 'meaningful, lasting change across all organisations involved'. The family also called for a national review of guidance and training on mental health in police custody, and for greater scrutiny of private companies providing public services.

Mr Payne's family said they hoped the agencies would listen to the 'damning conclusion' and make the changes needed to prevent another family suffering in the same way.

Bharine Kalsi, the lawyer representing the Payne and Carter families, said the scale of the failures was 'breathtaking'. She argued the case exposed a wider problem in the ability of police systems to recognise when another part of the system had failed.

'Time and again in this case we saw the police missing signs that were obvious to members of the public,' she said. 'That looks like wholesale desensitisation by those who should be alert.'

A G4S spokeswoman said: 'We offer our condolences to the families affected by these tragic events.'

Third Arrest Exposed Acute Psychosis

The morning after the killings, Lewis‑Ranwell was arrested for a third time following an incident at an Exeter hotel. He was detained on suspicion of affray and possessing an offensive weapon.

A Mental Health Act assessment was then completed. It concluded that he was acutely psychotic, and he told psychiatrists he had been experiencing delusions about paedophiles and kidnappers before the deaths.

Detectives later linked him to the three killings and charged him with murder. He was found not guilty of murder by reason of insanity and detained indefinitely in a psychiatric unit.

The inquest heard Lewis‑Ranwell had a history of cannabis use and 'drug‑induced psychosis or paranoid schizophrenia'. He was listed as an interested person in the proceedings but did not take part and was not legally represented.

The jury's findings do not undo what happened in Exeter. They set out how, in the hours when intervention might still have been possible, multiple opportunities were missed.