Khabi Abrey death: Independent investigation finds ‘little evidence’ that Westcliff fire scenario would not happen again

The coroner gave his "most sincere condolences" to Khabi Abrey's family and friends (Image: Stuart Abrey)
The coroner gave his "most sincere condolences" to Khabi Abrey's family and friends (Image: Stuart Abrey)

Khabi Abrey was 32 weeks pregnant when she was killed as a result of a flat fire

The killing of a pregnant woman by an unmedicated schizophrenic could still happen five years on, a report has concluded.

Khabi Abrey, 30, was 32 weeks pregnant when she died in May 2016 as a result of a fire started by Lillo Troisi in the Grampian flats, Westcliff-on-Sea.

Troisi, who was 48 at the time, hadn’t taken medication for 18 months and pleaded guilty to manslaughter and arson in 2017.

Read more: ‘Each day is a struggle’ for Essex husband who lost pregnant wife in a fire

Now, an independent report into the scenario which led to Troisi starting the fire has found that similar situations could arise.

The NHS-commissioned report by Niche Health and Social Care Consulting was published on August 24 and gives recommendations to the mental health services who dealt with Troisi prior to the fire.

In its summary, the report found “little evidence” that a scenario like Troisi’s would not happen again.

“Systemic failures” before fire

Recently, an inquest at Chelmsford Coroner’s Court concluded that “systemic failures” led to the fire which was started on the ninth floor outside Mrs Abrey’s flat. 

Mrs Abrey, who was described as “loving, sweet, very thoughtful, gentle and innocent” by her widowed husband, died on May 9, 2016, as a result of inhalation of air fumes.

Khabi with her husband Stuart

In January 2015, Troisi, a paranoid schizophrenic for over 20 years, had been taken off the monthly injections which had kept him mentally stable for five years.

Following a move from Enfield to Southend-on-Sea, and despite his request for a continuation of the injections, Troisi had his medication changed to tablets. 

In the ensuing year, “multiple errors” by health care professionals meant Troisi was not put back onto monthly injections, including a rejected referral and a reduction in the tablets he was given – which he was not taking.

The unmedicated paranoid schizophrenic then started the fire on May 7, 2016, which would cause Mrs Abrey’s death.

Lillo Troisi, a paranoid schizophrenic for over 20 years, had deteriorated mentally before starting the fire (Image: Essex Police)

At an inquest summary on Friday, August 20, Coroner Sean Horstead found the fire to be preventable and said: “It’s clear that in that context the relapse of his severe mental issue of paranoid schizophrenia, I believe on the balance of probabilities the setting of the fire would not have occurred, had an early and appropriate review taken place.

“Had that course of action been followed and the fire had not been set, then Khabi would not have died.”

“Lack of concerted response”

After finding that local mental health services did not show “professional curiosity” when dealing with Troisi, the NHS England commissioned report said: “We found little evidence that a scenario like Mr Z’s would not arise today.”

In an internal investigation, Essex Partnership University NHS Foundation Trust (EPUT) apologised “unreservedly” for not listening to the concerns of Troisi’s family, who had noticed a deterioration in his mental state between 2015 and 2016.

The independent report showed that Troisi’s concerned family wrote, called and spoke in person to primary care and first response teams, but were usually directed from one service to the other.

EPUT said: “The Trust can only apologise for this lack of concerted response.

”The Trust (…) apologise unreservedly for not listening such that the family’s concerns were not heard or acted upon.”

Report’s recommendations

In its summary, the independently commissioned report concluded that EPUT’s internal investigation recommendations “did not sufficiently address” the key issues surrounding Troisi’s care and treatment.

The report suggested five recommendations to be completed within six months of its publication.

The report recommended that the Trust should evaluate the senior primary care mental health nurse practitioner role in south east Essex.

This is to establish whether the role has facilitated the management of depot medication, such as the injection Troisi received, and mitigated the risk of patients not receiving it.

Secondly, the report recommends that The Trust, Local Medical Committee and relevant Clinical Commissioning Groups should develop and agree a shared protocol for the administration of depot medication in the community.

The report says the Trust should ensure that electronic patient records only give staff access to the patient’s current GP contact details and that all other out-of-date contact details are archived.

After the “lack of concerted response” to Troisi’s family’s concerns, the report recommended that concerns submitted by families or members of the public about a patient should be documented.

These concerns should also be subject to an assessment and review, and subsequently acted on.

The report’s final recommendation was that a system should be put in place to make sure that internal investigation findings are shared with service users, as well as other affected parties such as their families.

EPUT’s response

In response to the publishing of the report, a spokesperson for Essex Partnership University NHS Foundation Trust said: “We offer our deepest condolences to the family and loved ones affected by this case and will thoroughly review and continue to implement the recommendations of the independent investigation to ensure any further learning is embedded.

“Patient safety is our highest priority and we have made changes to our service in the last five years, including enhanced training for staff around medications, introducing a review process if family members raise concerns, improved access to services through a 24/7 crisis response line, and having more mental health nurses in GP practices.”

The Trust added that since the incident in 2016, a number of actions have been taken to “address lessons learnt”.

These measures include a review of any identifiable risks when families raise concerns regarding a patient’s mental health, as well as “closer collaboration” between primary and secondary care providers.

Credit Essex Live

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