What happened
On 1 March 2017 a mental health assessment team visited Kevin Boarer, 57, at his mother’s house in Collingwood Close, Peacehaven, East Sussex. The team was two doctors and a nurse, Liam O’Reilly. Boarer was assessed and sectioned.
The two doctors then left, leaving Boarer in O’Reilly’s care while an ambulance was sent. The prosecution told the court the doctors acted on the judgement that O’Reilly “did not judge Boarer to pose a risk of threat”.
While O’Reilly was alone with him, Boarer attacked from behind with a large knife and slashed him across the nose. O’Reilly also suffered cuts to his head and hands. He disarmed Boarer and left the house.
The outcome
Boarer was transferred to a psychiatric hospital and was found to have had mental capacity at the time of the attack. At Hove Crown Court in October 2017 he pleaded guilty to assault occasioning actual bodily harm. Judge Paul Tain sentenced him to twelve months’ imprisonment, suspended for two years, with twenty-five rehabilitation activity days.
O’Reilly’s injuries needed several stitches. He was left with a permanent scar and loss of sensation at the end of his nose.
What went wrong
The visit had three parts: the assessment, with two doctors present; the handover, when they left; and the wait. The risk was managed in the first and dropped in the third.
The doctors’ judgement was about the man. It was not about the room. A sectioned patient in his mother’s house still has a kitchen, and a kitchen still has knives. The assessment had taken place in a front room and the danger was in the rest of the building.
The plan then depended on an ambulance. Until it arrived, one nurse was the entire control on a man who had just been detained against his will, in his own home, with no colleague and no stated check-in.
What it teaches
The handover is the highest-risk minute of a two-plus-one visit. The moment colleagues leave, the arithmetic changes: one worker, one service user, a private house, and a door that is not yours to control.
For the clinician who is left: stand near the exit rather than the deepest room, check the man’s hands are empty and the room’s knives are out of reach before the others go, keep the phone in your hand with the dispatcher already on the line, and treat the assessment as over once you are alone. For the sending team: do not use one nurse as the wait-room cover for a freshly sectioned patient. If that is unavoidable, say who is coming, when, and what the nurse should do if it does not arrive.
Questions for the room
- When two colleagues leave and you are the last one in the room, what changes about where you stand?
- If the ambulance is twenty minutes away, where do you wait, and what do you do with your hands?
- A patient has passed your risk assessment. Which factors in a private home does that assessment not capture?
- Who decided one nurse was enough cover for the wait, and is that decision written down?
Evidence and limits
Confidence: probable. One source was read in full, the Argus of 31 October 2017. The pack holds no trust or NHS review, no psychiatric report and no victim personal statement, so nothing here describes what the trust required of the team or what its lone-visit policy said. The account of the doctors’ judgement is the prosecution’s summary as the newspaper reported it. The injuries are described only as far as the lesson needs them.
Our lone working training covers lone visits and handovers like this one.
Sources
- The Argus, October 2017 · https://www.theargus.co.uk/news/15629616.kevin-boarer-attacked-mental-health-nurse-at-his-mothers-peacehaven-home-leaving-him-scarred-for-life/
Reviewed 20 October 2026.