Richard Linford injured Christopher Edwards so badly that the dead man had to be identified by dental records after the two men were put into a cell together in Chelmsford prison to free up another room.
The report into the care arrangements for Linford heavily criticises the police, the prison service and the North Essex Health Authority. It notes that a month before the fatal attack, Richard Linford was judged "capable of murder" and described as "the most intimidating patient" one doctor had ever encountered, at a case conference attended by 10 key professionals, including the police and consultants.
On 29 November 1994, 30-year-old Mr Edwards, an honours graduate who spoke several languages but had been diagnosed with psychiatric problems, was taken to Chelmsford after he accosted a woman in the street.
Half an hour after he arrived, Linford was brought in. He had been fighting and causing trouble earlier that day and was initially considered unfit to be housed with other inmates. He had also attacked two police officers in Chelmsford when he was arrested and punched one during finger-printing. It took four of them simply to handcuff him.
Yet one hour after he arrived at the prison Linford was moved in with Mr Edwards. At first the two men seemed to be getting on, but at about 1am a prison officer heard a disturbance in the cell and raised the alarm. Linford had knocked Mr Edwards to the ground then jumped repeatedly on his head, crushing his skull beyond recognition.
Linford was later sent to Rampton hospital "without limit of time" after admitting manslaughter on the grounds of diminished responsibility.
Paul Edwards, Christopher's father, is campaigning to change the law covering the treatment of mentally ill patients. "There is a long litany of failures of communication between all the agencies, health and criminal justice, as all the other reports have shown," he said.
"If these young men could have got proper treatment - because neither of them had any insight into their illness - then Christopher would not have lost his life and Richard would not have lost his liberty."
Marjorie Wallace, chief executive of Sane, said that the charity had seen evidence that noted how potentially dangerous Linford was. "It is quite unforgivable that, after having a case conference involving all the people caring for Richard Linford, including the police, and despite the fact a doctor said he was capable of murder, it was decided no further case conference would be held," she said. "He was placed in a prison cell with another mentally ill young man arrested on a minor offence of importuning a woman in the street. Both needed hospital care not a prison cell."
Sane is publishing an analysis of homicide inquiries involving mentally ill people which concludes that one in three deaths was either predictable or preventable. In half of the cases studied authorities failed to consult families or carers or heed their warnings.Reuse content