The inquests into the deaths of Ruth and Christopher Stone-Houghton concluded on 15 December 2025 at Portsmouth Coroner’s Court, before HM Assistant Coroner Rachel Spearing KC.
Ruth and Chris were happily married for 32 years, with loving and supportive family and friends. There was no history of violence or abuse in their relationship. In June 2022, 3 months before their deaths, Chris, who had undergone a of period stress whilst preparing for retirement during the COVID-19 pandemic, was diagnosed with psychotic depression. In July 2022 he was hospitalised under section 2 of the Mental Health Act 1983 under the care of Hampshire and Isle of Wight Healthcare NHS Foundation Trust, for a period of assessment and for his own safety after a serious act of self-harm whilst he was psychotic. The section was rescinded on 25 July and on 3 August he was discharged home. He then underwent a period of home treatment from mental health services and was cared for at home by Ruth. On 14 September 2022, in acts the Coroner found to be entirely out of character, Chris killed Ruth and then himself at their family home. The Coroner found that he was psychotic at the time and had stopped taking his medication.
The Coroner found multiple failings in the care provided to Chris and the support provided to Ruth by the Trust. These included that Chris was placed on a non-acute older persons’ wards in a “hosting arrangement” which was chaotic and disjointed; and that his discharge from inpatient care was unsafe due to an inadequate risk assessment, care plan and package of care to be provided in the community. She further found that accessing mental health services, managing Chris’s complex condition and the responsibility for his compliance with medication was burdensome for his family, and that they found his mental health care a deeply distressing and an unfamiliar area to navigate. She found there was a failure to fully support the family in line with policy and practice, including by failing to carry out a formal carer’s assessment for Ruth.
However, in a finding that their family do not accept, the Coroner held none of those failures could be held on balance to be causative or contributory to the deaths, given the unpredictable nature of Chris’s illness.
In a notable finding in coronial law, the Coroner found, following the principes set out by the Divisional Court in R (Bryan) v HM Assistant Coroner for Buckinghamshire [2024] EWHC 26 (Admin), that due to his psychosis, it could not be said that Chris was legally sane at the time of the deaths. The elements of the criminal offence of manslaughter could not, therefore, be made out, and a determination of unlawful killing could not be made. She also was unable to find that Chris intended to take his own life. Narrative conclusions were returned in both inquests. The Coroner will go on to determine whether a Report to Prevent Future Deaths should be made.
The Coroner praised the composure, care and compassion demonstrated by Chris and Ruth’s children Oliver and Abigail Stone-Houghton throughout the inquests. In a statement following the inquests Oliver and Abigail said:
“Throughout this inquest, we have listened to every word and done our utmost to conduct ourselves in a way that would have made our parents proud.
More than three years after losing them, nothing could have prepared us for the emotional toll of hearing evidence during the past week of disjointed care, inaction, inadequate risk assessments and missed opportunities. It has been retraumatising. We couldn’t have got through this week without the family and friends who have filled the court daily to support us.
Our parents’ inquest heard evidence of clear failings, a number of which were recognised by the coroner. In light of the coroner’s findings that Dad had stopped taking his medication at the time of their deaths, and the evidence that steps were available to monitor medication compliance, it is clear that more could and should have been done to manage the risk of Dad becoming unwell again. The burden on our family to manage this was heavy. We do not accept that this could not have been foreseen.
Throughout our Dad’s illness, we saw that our parents did not receive the help they were entitled to and deserved, despite our desperate efforts to secure support. The severity of Dad’s illness was not recognised, nor was Mum’s role as a carer. These failures to truly see them and their needs cost them their lives and their deaths were entirely avoidable…
We welcome the changes now in place for those using the services of Hampshire and Isle of Wight NHS Trust. However, it is deeply troubling that these changes came only as a result of the deaths of our parents, and too late to save them. Their deaths should not have been the catalyst for action. We hope these changes lead to lasting improvements and prevent other families from suffering the devastating and avoidable loss that we have.
We say this directly to the Health Secretary, Wes Streeting: this inquest has exposed serious failings in the provision of mental health services. The lack of care our Mum and Dad received was not an isolated or local incident, and the lessons from this must be addressed nationally…
We were a close and loving family, no different from countless others. Please do not assume it cannot happen to your family. It can happen to anyone. To families seeking help for a loved one with mental ill health: trust your instincts. You know them best. If you are not being heard, keep pushing. Mental ill health is isolating and overwhelming, and families should not have to battle a system that is not fit for purpose. By speaking out, we hope others recognise the signs earlier and keep asking for help until it is taken seriously.”
Oliver and Abigail Stone-Houghton were represented by James Robottom, instructed by Sarah Ricca and Betty McCann of Deighton Peirce Glynn.
If you have been affected by any of the issues in this article the Samaritans can be contacted on 116 123.
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