It was one of the most inexplicable tragedies Norfolk has seen, a grandmother killed in a fire set by her grandson. Vera Croghan's inquest was supposed to provide answers. But, says DONNA-LOUISE BISHOP, it just raised more questions
After Chanatorn Croghan was arrested for starting the blaze that killed his grandmother, Vera, at her home on Unthank Road in December 2020, detectives began to trawl his background.
They found that Marco, as he was known to the family, had grown-up in Thailand but in 2017 he moved to Norfolk as a young teen to be with his father following a violent attack on his mother with a BB gun.
Officers also found a long history of his dealings with mental health services in the UK, including the chilling detail that he had been assessed as posing a high risk to others, six months before the fateful fire.
Police also began to piece together what they knew 89-year-old Vera, a respected former UEA academic and author of a best-selling Teach Yourself Swedish book.
Here, the evidence indicated that officials seemed far less concerned with her than they had been about her grandson, who was staying with her.
No checks were made on her living conditions, for instance. No one asked her what her wishes were about his presence in the house or made any assessments of her safety.
This discrepancy in the treatment between the two emerged at the inquest last month into Vera's death.
And it has added to the grief of her family.
Three of Vera’s four children - Karin, Mike and James - were represented at the hearing by Leanne Devine, partner at Leigh Day.
"There was a lack of professional curiosity concerning Vera’s wishes, her wellbeing and her safety," Ms Devine said.
FRUSTRATION REMAINS
The four-day inquest ended with Yvonne Blake, the area coroner for Norfolk, concluding that Vera was unlawfully killed.
But the process left the family frustrated and disappointed.
They had hoped that more scrutiny and attention would be paid to the way police, mental health services and adult social care officials dealt with Vera and her grandson.
They were particularly frustrated by the coroner's decision not to obtain Marco's mental health records, so as to make sure his privacy was respected.
ALARMING HISTORY
In the absence of those records, though, plenty of alarming details did emerge, however.
Following his move from Thailand, Marco studied at Wymondham College Sixth Form.
When he was not boarding, he would stay with his grandmother in Norwich.
It was not necessarily a very settled arrangement, however. In early 2019, Vera broke her arm and Marco was unable to stay with her, instead staying at an Airbnb.
After school, he secured a place at Reading University, but dropped out in early 2020.
Marco returned to stay with his grandmother where on May 31, he suffered a psychotic episode.
The following day, he was assessed as being a high risk to others and was sectioned under the Mental Health Act at Southern Hill Hospital, a mental health facility at Mundesley on the Norfolk coast.
During his treatment, Marco said he had a phobia about his grandmother not liking him.
No safeguarding alerts were raised, and this information did not factor into the subsequent discharge planning or risk assessments.
He was discharged on June 18.
RISK REDUCED
By then, his risk to others had been reduced to low with a factor being his compliance with medication.
He assured staff he would take his prescribed medication and stop taking illicit drugs.
However, he did not and began using cocaine and cannabis again. He also appeared to be abusing alcohol.
Marco was transferred to the Community Early Intervention Team (EIT) where it became known to the team that he was living with his grandmother.
No enquiries were made concerning Vera’s wishes or to assess the potential risk to her.
'SPIRALLING OUT OF CONTROL’
In September 2020, Marco left Norfolk to study at Manchester University, where he is believed to have been interested in studying the topic of artificial intelligence as part of a degree.
He was discharged from mental health services in Norwich and, in doing so, did not give consent for his medical history to be discussed with the mental health services in Manchester.
His fellow students described his behaviour from the outset as being strange and unsettling, becoming worse as that first term went on.
He was described as “spiralling out of control” to the point his flatmates contacted their residential life co-ordinator.
Marco refused to engage with them or have counselling. He left his course soon after.
RETURNING TO NORWICH
The day before Vera’s death, Marco returned to her house in Norwich unexpectedly with plans to stay there again.
His Norwich referral had been kept open, and he told Norfolk and Suffolk NHS Foundation Trust (NSFT) EIT during telephone calls that he was no longer taking his medication – a major factor in reducing his risk.
Meanwhile, his father, Richard Croghan made numerous contacts with the EIT, including the day before the fire was started.
He was told an appointment for Marco could not be arranged until six days later.
THE NIGHT OF THE FIRE
Shortly after midnight on December 11, Richard called police to the Unthank Road property.
He said he had become alarmed after his son's demeanour changed quickly and suddenly “out of the blue” following his unexpected return from university.
Marco had been watching television with Vera before she went to bed, but then became caught up in a conversation with his father about using his phone.
Richard described being "terrified for his life” after Marco became “blank and expressionless” with “no concept of thought”.
Police talked to Richard but left the property shortly afterwards as no criminal offence had been committed.
Richard then also left the house a short time later, believing Marco posed no risk to his sleeping grandmother.
Hours later, Marco started the fire that would kill her.
An investigation by Norfolk Fire Service found it had been set in a cupboard under the stairs.
Its location appeared deliberately selected because Marco had moved furniture to get to the cupboard.
At around 6.40am, a woman delivering papers discovered the fire and raised the alarm.
Firefighters discovered Vera's body inside as they tackled the blaze.
A Home Office post-mortem examination later found that she died from smoke inhalation.
Her face and hands were also badly burned.
Marco was not at the property when police and fire crews arrived, but he returned there that afternoon and was arrested.
While being held at a secure unit, he carried out Google searches for 'how to get away with arson'.
He appeared at Norwich Crown Court in February 2022 where he admitted manslaughter by diminished responsibility and arson.
He was later given an indefinite hospital order. Judge Anthony Bate imposed a restriction under Section 41 of the Mental Health Act 1983, noting that generally a person subject to this is not discharged without approval of the Secretary of State for Justice.
NO COMFORT
None of this has given much comfort to the family, who claim there has been a missed opportunity to learn lessons from the tragedy.
Vera's daughter Karin Ronen said: “We feel there has been no justice, and so many questions remain, in our opinion, deliberately unanswered.
“What is needed is joined up thinking to prevent such tragedies, but this will never happen unless there is true accountability when things go wrong.”
"I believe Marco’s a very dangerous person.
“He's not safe to be free. I know that I would be a target, and for the wider public I believe he should not be let out.
“However, I feel he was let down by the system. He was a very vulnerable person. He may not have known it, but he was, and he needed help.”
Julian Hendy from the Hundred Families charity, which supports families after mental health related killings, added: “We are concerned about the quality of care for seriously unwell people who need urgent, assertive, mental health care and treatment in Norfolk.
“We have documented 40 homicides by patients of the trust in the last 20 years. We believe many of them could have been prevented.
“We are aware of enduring concerns about safety at the Trust and calls for a public inquiry.
“Too many families are being failed. The Trust does need to show they are listening and acting urgently to prevent further avoidable tragedies.”
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