Sobhia Khan: Coroner makes extensive criticisms of failures in supervision and monitoring of restricted patient following murder

Sobhia Khan died on 27 May 2017 at the hands of her partner Ataul Mustafa, who was being monitored in the community as a restricted patient under the direct care and supervision of the Ministry of Justice, Derbyshire NHS Healthcare Trust and the Derby City Council, alongside Derbyshire Police. He had recently been released from Cygnet Hospital Derby. 

Mustafa had received a hospital order after brutal sexual and violent offending against his first wife which sadly paralleled his later offending against Sobhia. He had pathological jealousy and was extremely controlling. While in Cygnet, he had failed to comply with rules including, most significantly, conducting a concealed affair with a healthcare assistant who later disclosed the relationship and made serious allegations about his violent and controlling behaviour toward her. These concerns were not acted on. Mustafa was nevertheless identified as posing a particular risk to women he was in a relationship with and on release was obliged to report if he entered a new relationship. He was discharged into a standard community mental health team with no forensic experience. He did not disclose his relationship to Sobhia and despite information being provided to authorities that he was engaged to marry a woman from Bradford, she was never identified or contacted. Mustafa was in a relationship with Sobhia for around a year and was able to marry and move her into his home. She was killed just over a month later.

After a six-week inquest, the inquest into Sobhia’s death identified extensive failings by the agencies who were tasked with managing Mustafa. These included:

• Failure to provide the treatment expected at Cygnet Hospital, which impeded any proper assessment of risk going forward, and without which discharge should not have been considered;

• Failure to properly investigate, recognise and act upon offence-paralleling behaviour by Mustafa at Cygnet, including carrying out a concealed affair with a healthcare worker and the nature of allegations made by her about the relationship;

• Failure by Cygnet to inform the Ministry of Justice of such behaviour;

• An inappropriate decision to discharge, with a fractured approach, no joined-up thinking and a preoccupation with mental health as opposed to, and at the expense of risk;

• Inadequate arrangements for Mustafa’s supervision in the community, in particular the absence of forensic supervision and insufficient attention on the risk to the public and to women. There was insufficient attention to his manipulative behaviour;

• Failure to advise the Ministry of Justice when Mustafa’s niece disclosed that he was in a relationship with a woman who he intended to marry in February 2017; and

• Failure in the Police response to the niece’s disclosure which was a missed opportunity to discover the relationship with Sobhia.

The Coroner found that the Police’s failure to appropriately respond to the niece’s disclosures had probably contributed to Sobhia’s death as investigation would likely have revealed the relationship and allowed action to be taken to protect Sobhia. 

The Coroner will be making multiple reports to prevent future deaths directed at all of the Interested Persons including concerns about poor record-keeping which created unresolvable conflicts of evidence; the over-reliance on Mustafa’s self-reporting, including as to whether he had entered a relationship; the lack of independent scrutiny of Mustafa’s discharge by a Mental Health Tribunal; the lack of forensic pathways available for Mustafa’s care in the community; and the scope of the Ministry of Justice’s powers to recall.

Matthew Gold, solicitor for Sobhia’s family, states: “It has taken almost 7 years to conclude the investigation of the circumstances leading up to the death of Sobhia, a beloved and very much missed family member. Her mother Khalida and brother Javed have been at the forefront of the fight to obtain justice.  The family are very pleased that the public authorities tasked with monitoring Mustafa and protecting Sobhia have been held to account but found to have been seriously wanting.  Javed sincerely hopes that lessons will be learnt from the findings so that the victims of domestic violence from a known brutal perpetrator can be better protected and that their families do not have to suffer the same anguish, torment and upset.”

Sobhia’s family is represented by Fiona Murphy KC and Rosa Polaschek of Doughty Street Chambers, instructed by Matthew Gold of Gold Jennings Solicitors.