An inquest jury has criticised police failings over the killing of the academic Dr Jeroen Ensink, who was stabbed by a stranger suffering from psychosis as he posted cards announcing the birth of his daughter.
Returning a narrative verdict of unlawful killing, the jury highlighted failures and inadequacies by Metropolitan police officers, who had arrested Femi Nandap, then 23, for possession of a knife seven months before the Nigerian student stabbed Ensink, in December 2015.
Charges against Nandap were dropped six days before he killed Ensink, a senior lecturer in environmental health at the London School of Hygiene and Tropical Medicine. Ensink was killed just yards from his flat in Islington, north London.
Ensink’s widow, Nadja Ensink-Teich, sobbed and several jurors were in tears as the verdict was delivered at St Pancras coroner’s court in London.
“Based on the evidence we have heard there were a number of failings in the arrest, charging and custody of the individual in question,” the verdict said.
“As a result, he did not receive any mental health care, treatment or monitoring in the UK. It is possible these failures could have had an effect on Dr Ensink’s killing, but we cannot be certain.”
Nandap had been arrested in May 2015 after a violent struggle and bailed.
The jury highlighted several missed opportunities where Nandap’s deteriorating mental health could have been identified earlier, which might have led to him receiving treatment.
In a statement, Ensink’s widow said the inquest had “revealed numerous failings”.
“Taken alone, those failings may seem minor to some and may not be taken seriously by police, but collectively, they show a system that repeatedly failed and placed the public at foreseeable risk.
“Even more than that, the inquest has exposed a lack of professionalism on the part of the police and a lax attitude towards prosecuting knife crime.”
The Crown Prosecution Service has admitted the decision to drop charges of possession of a bladed article and assaulting a police officer was wrong, but said that as Nandap would have been on bail, it would not have prevented him from being in the street armed with a knife on the day he stabbed Ensink.
The coroner Mary Hassell told jurors that the charges being dropped had no causal link to the tragic events which followed and they should not assume it had an impact.
Nandap was convicted of manslaughter on the grounds of diminished responsibility and in October 2016 was sentenced to an indefinite hospital order.
His sister had warned police he was suffering “depression, anxiety, paranoia and hallucinations”, and was a heavy cannabis user. The jury found the failure of a custody sergeant to properly record mental health concerns was a missed opportunity and that the police computer system was “not adequately set up” to flag such warnings.
It meant the doctor, who carried out a fitness for interview examination, was denied information. If it had been available to him, the doctor could have conducted an indepth assessment that may have revealed mental health problems, the jury found.
Officers had failed to create a Merlin report – the system the Met uses to flag vulnerable adults to officers, social services and other agencies. The handover of information between officers was “unsatisfactory”.
More than two years after her husband’s killing, Ensink-Teich said: “The Metropolitan police have still not confirmed to me directly that they accept their failings or apologised for them.”
Ensink, 41, from Zwolle in the Netherlands, was an internationally renowned water engineer. He was killed just 11 days after the birth of the couple’s first child, a daughter, Fleur.
Ensink-Teich, who was forced to crowdfund to pay for legal representation after being denied legal aid, said: “I hope that the process of the inquest allows Fleur and I to move forward with knowledge that after two-and-a half years I can say that I did everything I could to expose any failings and missed opportunities that played a role in this tragedy.”
She added: “Now is the time for definitive changes to be made to prevent another family suffering in the way in which we have.”
Ensink-Teich, a project manager who moved back to the Netherlands after her husband’s death, told the Guardian she felt grateful to the jury. “To know that they came to the same conclusions as I had. I needed it to be heard, I needed it to be said in court, and for people to hear it.
“It confirmed everything I knew all along. Taken apart, each failing seems minor. But altogether, it just shows a system that isn’t working. That is what I found really difficult when it came to the verdict, it was one failing after the other, after the other.
She added: “This must never ever be allowed to happen again. When it comes to the preventing future deaths report, it’s so important to me that it is not just empty promises. Now they need to make changes.”
Supt Nick Davies, from the MPS central north command, said the Met had already made changes as a result of the case, and had referred itself to the Independent Office for Police Conduct.
Officers should have completed a Merlin report, and an internal review had recommended completion of such reports should now be mandatory, he said.
“. We will examine this verdict to see if there is more we need to do,” he added.
An investigation by the Directorate of Professional Standards (DPS) had found there were no misconduct matters “but some areas of learning were identified for the officers who came into contact with Nandap, around best practice for dealing with suspicions of mental ill-health”.
In her statement, Ensink-Teich said: “I am dreading the moment when Fleur asks me why she doesn’t have a father and I have to explain.
“We have settled into our new life in the Netherlands, but it is nothing like I ever imagined. I miss what was, but more than that, I miss what could have been. I miss the life we were supposed to have. I miss hearing him tell Fleur how much he loves her. I miss the children we will never have. I miss the twinkle in his eye. I miss his laugh. I miss his touch and the sound of his voice when he’d tell me he loved me.”
