A CATALOGUE of errors, government policies and an underfunding of the mental health service were to blame for the death of a Lindford woman at the hands of her schizophrenic son, a formal inquiry has found.

Lena Huntingford (86), of Mill Lane, was killed by her son Paul on Christmas Eve 1997.

She died from asphyxia while he was performing a do-it-yourself exorcism because he thought that his mother was possessed by the devil.

He was found not guilty of murder by reason of insanity after a trial in November 1998, but he was one of three mental patients in the north and mid Hampshire area who were responsible for killings within the space of two years.

This prompted the independent inquiry, commissioned by the North and Mid Hampshire Health Authority and Hampshire County Council, which described the deaths of Mrs Huntingford and the two other victims as a "national responsibility".

The inquiry, of which details were released last week in a 144-page report, says that Mr Huntingford (now 60) was failed by a lack of financial investment in resources and mistakes in his care.

The report describes Mr Huntingford's case as "highly unusual" and says that despite an assessment of 1,500 homicide suspects, there have been no similar cases.

However it says that poor communication between staff and with Lena Huntingford were important factors leading to the Christmas Eve killing.

"The medical files contained very little information concerning his psychiatric and personal histories, and his social circumstances.

"Important information held by the GP was not sought by, or made available to, the hospital and community mental health services.

"At some stage during Mr Huntingford's long contact with services his mother should have been seen, perhaps quite informally, on her own.

"Too many assumptions were made about her relationship with her son, and more attention should have been given to the nature of this relationship and its effects on the course of his illness.

"There was some evidence that she found it difficult to acknowledge his illness, may not have fully understood the importance of medication, and was sympathetic to the negative effect the previous admissions had had on him."

The report says that because the former music teacher was only assigned a key worker for a period of two months, it led to his breaking off contact with the mental health service professionals.

"Because Mr Huntingford was not considered a risk to others - although there was evidence available that he was - his views prevailed as to what, and how much, prophylactic medication he would take, and which health care professionals he would see, and under what circumstances."

Examining the events which directly led to the death of Mrs Huntingford, the inquiry team highlights the fact that for three months before Christmas Eve, Mr Huntingford thought that his mother was possessed by the devil and had been seen and discharged by medical staff during this period of time.

On December 23, 1997, he was assessed at home by a consultant and an approved social worker, neither of whom knew the Huntingfords, who decided that he required compulsory admission to hospital.

However psychiatrist Dr Lena Roy mistakenly dated the admission form November 23, making it invalid, which meant that Mr Huntingford could not be taken to hospital that day.

A second order was made out the following day - but it was too late.

"The visit on December 23 1997 should have been better planned, although staff should be praised for responding rapidly to the request for a Mental Health Act assessment.

"Although there was no evidence that Mr Huntingford intended to harm his mother when the approved social worker was asked to leave his home on the evening of December 23, she left a situation destabilised by the visit.

"It was unfortunate that the patient's consultant was unavailable for consultation, and that there was therefore no medical opinion of the risks involved in deferring admission until the following day.

"Following Mrs Huntingford's death, the fact that one of the medical recommendations had been incorrectly dated received considerable attention. This ought to have been properly scrutinised before the doctor who completed it left the household."

However the report also puts a large proportion of the blame for this case, and the two other cases, on an underfunded mental health service.

It says that there was little investment in mental health services until after Mrs Huntingford's death, and that Hampshire County Council "was a relatively low spender on mental health services" at that time.

This led to low staff morale and an increasing lack of resources.

The report said: "The consequence of all this was that local people did not have the benefit of a comprehensive or adequate range of mental health services during the period covered by our review.

"In our opinion, inadequate resources require families and professional carers to accept risks which they ought not to have had to bear.

"The government and the county council of the day must accept responsibility for consequences arising from, or associated with their funding decisions."

Mr Huntingford is still detained and is receiving treatment under the Mental Health Act.