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The family of a woman killed by a man with psychosis have said she “paid with her life for lapses in the English prison and policing system” after a coroner said failures by prison and police authorities contributed to the killing.
In a damning verdict, the senior coroner for Dorset, Rachael Griffin, said Marta Elena Vento, 27, a Spanish national, was unlawfully killed by Stephen Cole in December 2020 while she was working as a receptionist at a Travelodge hotel in Bournemouth.
In the summer and autumn of 2020, Cole had been on remand in Winchester prison for indecent exposure. He attacked two fellow inmates and two staff members, one of whom needed hospital treatment.
He was assessed by prison psychiatrists, who judged he had psychosis or possible paranoid schizophrenia and was prescribed olanzapine, which stabilised him. The healthcare services were run at the prison by a private health provider, Practice Plus Group (PPG).
Cole was unexpectedly released on 27 October 2020 with only a month’s worth of the medication. After it ran out, he attacked two people at the accommodation where he was staying and was placed in the Travelodge where Vento worked by his family after he was evicted from another hotel where he had been placed by the housing authority.
On 9 December, Cole punched, kicked and attacked Vento with hair clippers. The attack lasted for 42 minutes, in which Vento sustained 55 injuries. She later died.
Recording a narrative verdict on Friday, Griffin said: “Marta Elena Vento was unlawfully killed by another who, at the time of her death, was unmedicated for a diagnosed mental health illness because of a failure to sufficiently plan and ensure the continuity of his mental healthcare upon his release from prison six weeks prior to Martha’s death, and because he was not adequately managed as a sex offender in line with national guidance on his release from prison.”
After the hearing, Vento’s family issued a statement. “Today’s conclusion confirms what we have suspected in the four long years since our dear Marta was torn from our lives,” it said.
“It is overwhelmingly hard for us to understand how the English prison health system could allow someone like Stephen Cole, who was so clearly unwell, to be released without a care plan and the ongoing medication he needed.
“It is equally hard for us to understand why the English police did not make themselves fully aware of the danger Cole posed when he stayed at the Travelodge on that night.
“Our daughter paid with her life for lapses in the English prison and policing systems. The cost to our family can never be measured. Without our Marta, our lives will never be the same.”
In her concluding remarks, the coroner said that a discharge summary was not sent to Cole’s GP upon his release from prison, nor was there a referral to the mental health team to continue his care.
“At this time, there was no integrated mental health policy in place within the healthcare department of the prison,” she said.
“There was a lack of comprehensive care planning infrastructure across prison healthcare nationally and the prison healthcare team were experiencing pressures arising from reduced staffing following the mobilisation of the healthcare contract at the prison and the impact of the unprecedented Covid-19 pandemic.”
Griffin said Cole was given medication upon release from prison, but there was no “continuity of the mental health care” and it soon ran out, leading to a relapse of psychosis.
Dorset police’s team dealing with violent and sexual offenders was responsible for managing Cole in the community, the inquest heard.
Griffin recorded that there was “incomplete information gathering to identify, assess and manage his risks in the community, and no Armss [at-risk mental state service] risk assessment was completed or management plan put into place in respect to the perpetrator prior to Marta’s death”.
The inquest previously heard that just before the attack, Cole told a police offender manager he was being spied on through the smoke alarms at the Travelodge and people were knocking on his window, though he was on the fourth floor.
Also, shortly before, Cole’s family arranged for him to see a GP to try to get more olanzapine but the doctor said he was not able to without details from those who had prescribed it.
In 2021 Cole pleaded guilty to manslaughter by reason of diminished responsibility due to a psychotic episode and was given an indefinite hospital order.
