Killer's care mistakes identified in watchdog's report
An inquiry into the killing of a Merthyr Tydfil man by his neighbour has concluded that mistakes were made by care agencies.
Bipolar patient Granville Jones, 61, killed Kenneth Auger, 64, with a claw hammer in December 2008 after suffering years of mental health problems.
Healthcare Inspectorate Wales found the murder could not have been predicted but identified failings in Jones' care.
Cwm Taf Health Board and Merthyr Tydfil council fully accept the findings.
Jones admitted manslaughter on the grounds of diminished responsibility and was detained under the Mental Health Act.
An investigation was ordered after Merthyr Crown Court heard that Jones had tried to seek help in the months before the attack.
The review found it was "clear that there had been a lack of holistic care planning" in the case.
It found that important information about Jones' illness and history was missed because services developing a care plan for him did not involve his family.
The review found there was "some confusion" over where responsibility lay for the co-ordination of his care, inconsistencies in thee way services referred care between them and shortcomings in communication.
It also found there was "little evidence to demonstrate that services had made any assertive attempt to engage and treat" Jones over the 40 years he was involved with mental health services.
The report makes 18 recommendations in total.
Health Inspectorate Wales Chief Executive Dr Peter Higson said: "It is important to stress that incidents like this are extremely rare.
"The purpose of our investigation was to identify learning to ensure that mental health services are better able to minimise the risk of similar incidents in the future.
"This review has highlighted some shortcomings in the care provided to Mr Jones and we will ensure that actions are taken to address these."
Merthyr Crown Court hearing was told Jones became angry because Mr Auger was looking forward to Christmas and had lots of greeting cards and visitors and Jones did not.
The court heard Jones had suffered psychotic episodes in the past and had attacked police officers.
But by 2007, the community mental health team lost touch with Jones when he failed to keep appointments.
Two days before the killing, Jones contacted a mental health centre and spoke to his social worker about feeling lonely and depressed.
His social worker advised him to contact the crisis team, but he did not.
Cwm Taf Health Board and Merthyr Tydfil council said they fully accepted the findings of the inquiry.
In a joint statement, they said: "We accept that there are always ways in which care and treatment of vulnerable people can be improved and have been working with our partners to address the issues raised."
It said the lessons to be learnt included "ensuring consistent recording and sharing of information, and improved regular communication between different elements of the service (for example between Crisis Resolution Home Treatment and the Community Mental Health Team and Day Unit)".