A man with paranoid schizophrenia who killed both his parents in separate attacks was let down by mental health services in Liverpool, a report has concluded.
Leslie Gadsby, 42, killed his father Philip in February 2004, and his mother Edna in March 2010.
Following the death of his father and a conviction for manslaughter, he was housed in Scott Clinic in Rainhill, a medium-security unit managed by Mersey NHS Trust.
He was conditionally discharged in 2006 following a Mental Health Review Tribunal and moved to supported housing.
The conditions of his release were that he not go within 200 metres of his mother's house, though they regularly met for lunch with the support of his key workers. He also had to take his medication.
However, his mental health continued to deteriorate and he went on to kill his mother, fatally stabbing her five times and setting fire to his flat.
He was jailed in 2011 after admitting Mrs Gadsby's manslaughter with diminished responsibility at Liverpool Crown Court, and is now detained at the high security Ashworth Hospital.
The report, written by Dr Androulla Johnstone, the chief executive of the Health and Social Care Advisory Service, told how on the morning of Philip Gadsby's death in 2004, his son had been due to be admitted to hospital as his mental health had deteriorated.
A social worker telephoned to make arrangements and a police officer answered and said Leslie Gadsby had killed his father and seriously injured his mother.
An independent investigation into the care and treatment of Mr Gadsby, known as patient Y, was commissioned by NHS North West strategic health authority. Published this afternoon, it made 13 separate recommendations.
It found there was a failure to understand Mr Gadsby in his full diagnostic context: "This in turn contributed to a failure to understand his risk and the future requirements of any care, treatment and management plan."
The risk assessment and risk management in the Scott Clinic was managed poorly, it stated.
"The quality of formulation exposed a lack of understanding of the risks that Mr Y posed and revealed a lack of understanding with he way the care team monitored him," the report said.
For the first two weeks of his discharge into supported accommodation, his medication was checked by staff at Imagine Independence, a Liverpool-based charity that supported him in social care in the community.
But after after a fortnight, he self-medicated unobserved.
The report recommended management arrangements and working practices at the Scott clinic should be reviewed "to ensure a consensus approach to decision making".
Before his mother's death, he failed to take his antipsychotic medication on a regular basis. The prevailing belief was he'd "somehow been cured" when it was "highly likely" he was masking his symptoms.
Ray Walker, director of nursing at Mersey Care NHS Trust, said it had been devastating for the Gadsby family, who had been very dignified throughout the judicial and report process.
"It's a fairly devastating report, really," he told the Independent. "It has been very sobering for us."
He said: "The situation 10 years ago is very different now and we have significantly more beds in secure medium units."
He said it was clear they had made mistakes, but added that mental health "is not an exact science".
Dr David Fearnley, medical director at the trust, said: “On behalf of the trust I would, once again, like to express our condolences to the Gadsby family. This was a tragic event that will live with them forever and everyone involved with in this case is devastated at the impact it will have on loved ones and friends.
“We welcome the publication of this report and its thorough investigation into the care and treatment provided to Mr Gadsby. We are committed to ensuring the care we give patients and their families is the safest it can possibly be.
“To that end, we have already taken action towards implementing the recommendations from the report.”Reuse content