Review critical of Cardiff killer Leyton Williams' care
A violent man with a history of mental illness went on to kill months after being released from prison without any supervision or care, says a report.
Leyton Williams stabbed friend Anthony Kitely, 39, with a shard of glass in Tremorfa, Cardiff, in June 2009.
He also injured his mother in an earlier attack on the same day after suffering paranoid delusions.
A health watchdog review found Williams fell through the system after leaving prison.
It blamed a "breakdown in communication between all agencies".
A joint statement from the agencies, which range from health boards to the prison, admits there were failings, apologises to all concerned and calls it a "tragic case".
Healthcare Inspectorate Wales (HIW) chief executive Dr Peter Higson said: "It is clear from our review that Mr Williams had a history of violence and mental illness.
"He was difficult to engage with and consistently denied that he had mental health issues and was therefore unlikely to seek help when his mental health deteriorated.
"Sadly a breakdown in communication between statutory agencies meant that following his release from prison in September 2008, Mr Williams' mental health issues went unmonitored."
Williams had been recalled to Parc Prison in Bridgend in July 2008.
The HIW review found a lack of effort by health and social care agencies to identify the prison so his mental health could be monitored.
After his admission to prison, opportunities were also missed to refer him back to mental health services, the report said.
Other concerns raised included:
- A breakdown in communication between all agencies meant that when Williams was released from prison, he was not receiving care, treatment or supervision from any statutory agency.
- Despite police raising concerns in relation to his mental health, further opportunities to "re-engage" with mental health services were missed.
- Neither the Caswell Clinic mental health service or Parc Prison near Bridgend were invited to Multi-Agency Public Protection Arrangements (Mappa) meetings held to discuss Williams' care. This led to "gaps in knowledge and understanding of the risk presented" by Williams and his health and care needs.
Mappa is the name given to arrangements for agencies who manage, for example, registered sex offenders, violent offenders and offenders who pose a serious risk of harm to the public.
HIW made 15 recommendations over Williams' care and treatment.
Williams, who knew Mr Kitely, was found guilty of his manslaughter on the grounds of diminished responsibility at Cardiff Crown Court in June last year.
He also admitted causing grievous bodily harm with intent to his mother, who survived the attack.
He is being detained indefinitely at a high secure unit under the Mental Health Act with restrictions placed in relation to his discharge.
The report says from the age of 16 until the manslaughter, Williams was convicted of 65 offences and he served four prison sentences.
He had suffered from delusions and received treatment at the Caswell mental health clinic in 2007 and 2008.
On the day of Mr Kitely's death and the attack on his mother, Williams had accused her of dyeing his hair silver and his eyebrows pink.
The report said he had become increasingly paranoid towards her and while suffering delusions, he shaved his eyebrows off and "viciously" attacked her when his mother made a comment about this.
Williams visited Mr Kitely, a friend, at his home later that evening, where there was an argument.
It appeared to stem from a delusion that Mr Kitely had written the word "nonce" on Williams' face and had earlier led to Williams coercing his friend into confessing this in writing.
Williams picked up a shard of glass from a broken mirror and stabbed Mr Kitely several times including a blow to his throat.
The following day, Williams knocked on the door of a house in Tremorfa, appearing dazed and upset claiming that he had assaulted somebody and was taken into custody by police.
After the trial last year, Mr Kitely's mother Gale said: "The panel that released Leyton Williams virtually signed my son's death warrant."
The family released a statement on Thursday welcoming the report's publication and saying they did not blame Mr Williams for their son's death.
Mr Kitely's family said: "After reading the report it has helped us to understand more about what led up to Anthony's untimely death.
"We do not blame LW for what happened, but the lack of a cohesive mental healthcare system, including the poor communication that led to his release.
"This one decision damaged all of our lives irreparably and in many different ways, from health to emotional growth.
"We live with a huge sense of loss that Anthony has gone, and hope that the publication of this report will give us a sense of closure."
A joint statement from the agencies involved, ranging from the health boards, prison, council to probation service, offered their "sincere and unreserved apology to all those involved."
They called it a "tragic case" and whilst the decision to discharge Williams was made by the mental health review tribunal, "we accept the identified failings that followed this decision".