The killing of a man by a mentally ill patient with a known history of violence on leave from a psychiatric hospital could have been avoided by better care, a damning report claimed today.
An inquiry into paranoid schizophrenic John Barrett found that the quality and care of his treatment "fell short in a number of areas".
Failures included insufficient monitoring of the patient, poor communication and too much emphasis on his wishes rather than what was safe.
This enabled him to abscond from Springfield Hospital in Tooting, south London, in September 2004.
He had been granted an hour's "ground leave" from the Shaftesbury Clinic, a secure unit, but failed to return.
The decision to give him that freedom by consultant psychiatrist Dr Gill Mezey was described by the inquiry as "seriously flawed".
On leaving the hospital, 43-year-old Barrett bought numerous kitchen knives, took a taxi to Richmond Park and repeatedly stabbed 50-year-old Denis Finnegan who was on his morning cycle ride.
Barrett said afterwards that he bought the knives because voices in his head were commanding him to kill.
He pleaded guilty to manslaughter and was sentenced to life in March last year.
He is currently being treated at Broadmoor Hospital.
The critical independent inquiry, commissioned by the South West London Strategic Health Authority, was chaired by mental health solicitor Robert Robinson.
The finding said: "We do not say it was predictable that John Barrett would experience command hallucinations telling him to kill, but the risk of serious violence associated with deterioration in his mental state was known.
"We conclude that one of the factors that contributed to the killing of Denis Finnegan was that John Barrett's illness was inadequately treated."
The inquiry went on to question whether the Shaftesbury Clinic should even remain open as a secure unit.
The 400-page report gave details of Barrett's former violent history when he stabbed three people at a clinic in St George's Hospital in 2002.Reuse content