Failures in the care of a paranoid schizophrenic who killed a pregnant mother of five were revealed yesterday by an independent investigation which highlighted a series of blunders leading up to the tragedy.
Tina Stevenson, 31, died with her unborn twins in January 2005, when she was stabbed in the street close to her home in Hull by Benjamin Holiday. The 25-year-old, described by police as "dangerous and troubled", had missed his medication the day before. Two months earlier he had been taken into a secure unit for a two-week assessment – one of six admissions to hospital over four years – but was later released. The report described this decision as a "missed opportunity".
The inquiry, by NHS Yorkshire and Humber, found Holiday's mental health problem was "under-treated", and his condition should have been "more assertively managed". It also concluded that he was at times able to dictate his own treatment.
The report admitted Holiday, referred to as B, was a difficult patient to engage with who was skilled at masking his symptoms. But it concluded: "The root cause contributing to B's continuing severe mental disorder was that of 'under treatment'. B's situation and condition could and should have been more assertively managed."
Holiday, who has no recollection of the attack, pleaded guilty to manslaughter at Hull Crown Court in 2006 and was detained indefinitely at a psychiatric hospital. His family blamed his actions on failings by the Humber Mental Health Teaching NHS Trust which claimed there was no evidence at the time of his assessment that he posed a serious risk to the public. Trust chief executive, David Snowdon, apologised and said he fully accepted the findings of the report.
Marjorie Wallace of the campaign group Sane said patients should not be able to decide treatment. "He didn't want people to interfere and yes, we ought to respect the rights of a mentally ill person, but not if they are out living in the community and not if they are a risk to themselves or others."
The trust also apologised after being criticised in the same report over the care of Michael Torrie a mentally ill man who killed his elderly mother in 2003 at their home in Pocklington, East Yorkshire, after a "rapid reduction" in his medication.