Blackpool health agencies ‘missed opportunities’ to prevent Conor Clarkson's brutal murder of grandmother in Stanley Park home

An independent domestic homicide review, completed in June 2022, found there had been a number of failings by health authorities, that may have prevented the 71-year-old’s death.

Mrs McCabe was killed by Conor Clarkson on Sept 04, 2019, at the home they shared in West Park Drive in Blackpool.

Failings included an ‘inadequate triage’ phone call to assess Conor Clarkson’s ‘complex’ mental illness in July 2019.

The report also recommended that mental health staff should take a domestic abuse awareness course to prevent future incidents.

Warning signs were missed

These findings were revealed on day three of an inquest into Mrs McCabe's death, at Blackpool Town Hall on March 08, 2023.

Mrs Carol Ellwood-Clarke QPM, an independent reviewer with a background in safeguarding and policing, discussed how a panel of 14 experts had looked at how the various agencies had responded to ‘indicators’ that an adult was at ‘risk of harm’ in the home.

Blackpool Teaching Hospitals and the Lancashire and South Cumbria NHS Foundation Trust (LSCFT) both had access to Mr Clarkson’s records, which showed he had a ‘history of excessive alcohol consumption and drug abuse’, and had engaged in behaviours that ‘posed a direct threat’ to his grandma – but these weren’t acted upon.

Mrs Ellwood-Clarke told the court there were ‘missed opportunities for referrals to services’, where the family could have discussed domestic abuse and risk.

‘Inadequate’ mental health telephone assessment

A 24-minute telephone assessment provided by Blackpool Teaching Hospitals’ was described by Mrs Elwood-Clark as ‘inadequate’. Conor’s triage assessment was carried out by Senior Mental Health Nurse, Angela Cox on July 12,2019. He was put on a nine week waiting list for treatment and had ‘no further intervention’.

Mrs Ellwood-Clarke told Assistant Coroner, Tim Holloway: "He should not have been placed on a waiting list to see a mental health practitioner. It should have been an urgent appointment, or at least seen sooner.”

The court also heard that staff at Blackpool Victoria Hospital’s A&E department had the chance to step in, where Conor was seen by several mental health practitioners on July 3, 2019.

None of the staff had completed domestic abuse awareness training, meaning they were ‘unaware of the risk factors’, and ‘did not consider the possible link between mental health and domestic abuse’, according to the LSCFT.

Mrs Ellwood-Clarke added: “If a high risk had been identified, a multi-agency risk assessment conference (MARAC) would have been undertaken, and a plan put in place for Marlene and Sharon.”

‘Very violent assault’

Yesterday (March 07), the inquest heard how Mrs McCabe had sustained a ‘very violent assault’ caused by severe blows with a blunt object’.

When police arrived at the scene, near Stanley Park, Conor was sitting on the wall outside, covered in blood. He had been shouting ‘I’m the devil, I’m a vampire’.

Just two months earlier, Mrs McCabe had written to the family GP, explaining how the whole family was ‘terrified’ that Conor would ‘end up in serious trouble if he [didn’t] get help’.

The hand-delivered letter, dated July 08, 2019, outlined some of her grandson’s bizarre behaviour – including ‘jumping up and down shouting Lucifer’.

On day two of an inquest into 71-year-old Mrs McCabe's death,an extract was read out.

It read: “We are both terrified of what might happen. We are that afraid that Conor has agreed that when he goes to bed at night we lock the door from the outside.”

‘Mistake’ in mental health referral

The inquest heard from Dr Paul Collins, a GP at Bloomfield Medical Centre, who first saw Conor in May 2019 to refer him to the Mental Health Team at Blackpool Teaching Hospitals.

He told the court that this style of personal letter was ‘highly unusual’ to receive, adding that during a consultation, Mrs McCabe said her grandson ‘wouldn’t hurt a fly’.

He recalled Conor was ‘visibly laughing’ as his carers voiced their concerns with the doctor.

Conor’s ‘complex history’ showed he’d been seen by medics in 2014 and 2017 for psychotic symptoms including severe paranoia and hallucinations, which Dr Collins said was likely to be ‘precipitated’ by his heavy cannabis use.

READ MORE: Conor Clarkson pleaded guilty to manslaughter and sentenced to secure hospital unit.

But Dr Collins admitted he hadn’t shared these incidents in his referral, which may have led to Conor getting seen more urgently if he had.

Alcohol and cannabis changed his behaviour

Conor had been living with his gran since he was five years old, after being removed from the care of his mother. He had been abused as a child.

Mrs McCabe was described as a ‘devoted grandmother’. The inquest heard how Conor’s behaviour changed when he started drinking and experimenting with drugs.

Cops thought he was a nice young lad with a supportive family

PC Vicky Rose had been called to their home on Dec 11, 2017, when Conor had been ‘arguing with his grandmother’. She told Assistant Coroner Tim Holloway that he seemed like a ‘pleasant young lad’ who showed ‘no red flags’ at the time.

She recalled having a chat with Conor on his bed, in his loft-room, and said: “He was chatty, and honest that he had been smoking cannabis. I got the impression he was a nice young lad with a supportive family.”

Pleaded guilty to manslaughter

PC Edward Daniel White was called to Stanley Park on 06 May 2019, when Conor threw a ‘partially empty can of beer’ at a jogger, in an ‘unprovoked’ attack.

He escorted the young man home, where his grandmother was ‘shocked and surprised’, saying that he was becoming ‘a little bit detached and less like himself’.

PC White said Conor's demeanour and behaviour changed once he was taken home. He recalled thinking that Conor came across like an ‘extremely polite young man’ around Mrs McCabe, and it was clear he had been ‘well brought up’.

Conor was sentenced at Preston Crown Court on Thursday, May 7, 2020. He pleaded guilty to manslaughter by reason of diminished responsibility. He was diagnosed with a severe form of paranoid schizophrenia, and sentenced to indefinite detention in a medium-secure hospital. He is said to be ‘progressing well’ with his treatment.

The inquest continues.