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The family of an honorary policewoman who was stabbed to death by her son during a "meltdown" has described her death as "avoidable" as they called for "systemic change".
68-year-old Pamela Nisbet died after being attacked on 6 August 2019 in the kitchen of her St Peter home by her son Andrew Nisbet.
The attack followed a long-running family dispute over Mr Nisbet's residence in his parents' annexe and requests for him to move out.
Nisbet faced the Royal Court a year after his mother’s death, when he admitted manslaughter on the basis of diminished responsibility and was sentenced to remain in a secure psychiatric hospital.
An inquest into the death of Mrs Nisbet resumed last week, and entered its final stage today.
Viscount Mark Harris, presiding over the inquest as Coroner, was especially critical of social worker Lisa Chapman, who was the authorising officer for a mental health assessment of Nisbet that took place on 1 August, but had disagreed with two clinicians about whether he should be detained.
Advocate Harris observed: "Had Miss Chapman acted as she should have done and made the application for admission under the mental health law it is probable that Andrew would have been admitted to hospital before he killed his mother."
He added: "Between January 2018 and July 2019, inadequate steps had been taken to assess and address Andrew Nisbet’s Autistic Spectrum Disorder and Asperger Syndrome and to try and ameliorate their impact upon his mental health and wellbeing.
"It is not possible to know what the outcome would have been had an adequate assessment of his neurodiversity been undertaken."
Following the conclusion of the hearing, Mrs Nisbet's family said in a statement: "This was an avoidable family tragedy. We hope that there will be systemic change in the future.
“We would like to express our thanks to the inquest for its thorough and diligent inquiry."
Pictured: Andrew Nisbet admitted manslaughter on the basis of diminished responsibility and was sentenced to remain in a secure psychiatric hospital.
They went on to praise the family doctor, David Bailey, who had held numerous meetings in a bid to manage the worsening mental state of Nisbet and his relationship with his parents.
Mrs Nisbet's family described him as an "exemplary doctor", lauding his "care, compassion and devotion".
They also gave thanks to “Jersey Police, all of whom showed exceptional skill and care, both before and after the incident, dealing with a complicated situation".
“Pam died as she lived, fearlessly going into harm’s way to try and help someone she loved. She is sorely missed," the family said.
Health's Chief Officer, Chris Bown, responded to the findings of the inquest this afternoon: "The inquest into the death of Pamela Nisbet has found that between January 2018 and August 2019 there were inadequate steps and failings in the assessment and care of Andrew Nisbet by mental health services.
"We would like to take this opportunity to extend our deepest apologies for these failings to Mrs Nisbet's husband and family. Whilst the Viscount recognised that significant changes have since been made to the provision of mental health services in Jersey, we recognise there is always more to do.
"We wish to assure the Nisbet family and those using our services that we are determined to continue to make improvements in our systems and processes within the mental health services."
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