Cardiff hit-and-runs 'would have been difficult to prevent'
A series of hit-and-runs in Cardiff which killed a mother and injured 20 others would have been difficult to prevent, a report finds.
Matthew Tvrdon, 33, was psychotic and hallucinating when he went on a "journey of mayhem" on 19 October 2012, at five locations.
He had stopped taking his medication, Health Inspectorate Wales (HIW) said.
It identified shortcomings in his care and a lack of monitoring of his condition leading up to the tragedy.
Karina Menzies, 32, from the Ely area, was struck while walking with two of her children outside Ely fire station. She pushed them out of the way before the van driven by Tvrdon hit her.
Tvrdon, who was suffering from paranoid schizophrenia, later admitted her manslaughter on the grounds of diminished responsibility.
He also pleaded guilty to seven counts of attempted murder and other charges including three counts of grievous bodily harm with intent during the incident which took place over eight miles of the city as parents were on the school run.
He told police on arrest he had targeted his victims because he mistakenly believed they had previously "gaslighted" him - a form of mental abuse that causes victims to doubt their own memory, perception and sanity.
On Thursday a report by HIW said that given the circumstances, it was difficult to see how Ms Menzies' death could have been prevented and it could not have been predicted.
The review said Tvrdon came from a stable and "very caring" family from Roath in Cardiff and only developed behavioural concerns while at university in 2002. He was forced to drop out and in 2003 was sectioned at Whitchurch Hospital, Cardiff.
It said he was psychotic and was under the care of Cardiff and Vale University Health Board from 2003 until 2012.
During that time he was sectioned in hospital four time, the final time in 2007, but he had never made any threats against members of the public.
The report said Tvrdon appeared to be "well and in the phase of recovery" and was working full time at Her Majesty's Revenue and Customs (HMRC) when he was seen for what was to be the final time by a consultant psychiatrist in October 2011 - a year before the tragedy.
He was advised to continue to take his medication for another year before gradually cutting it down until he stopped.
But it later emerged Tvrdon had stopped taking his medication almost immediately and had not been seen by any mental health services in the year before he went on the rampage in Cardiff.
The report said he had a history of not taking his medication and was reluctant to work with mental health services because he felt there was the stigma attached to it.
It said that when he did take his medication, he responded well and was able to have normal relationships and a job - but a relapse was likely if he stopped.
However, the severity of his condition was not properly communicated with his GP surgery, the report found.
It said mental health teams and GPs did not monitor Tvrdon's condition fully, particularly after he was sectioned and subsequently discharged in 2007, adding that there was no system in place to establish whether his prescriptions had been collected.
The report also highlighted the excessive workload of his consultant psychiatrist, who had responsibility for 300 patients, and said Tvrdon had been seen by nine GPs during his time under mental health services.
It made eight recommendations, including:
- Written plans must be shared among with all concerned agencies setting out the action to be taken if a patient's condition deteriorates
- Improve communication between mental health teams and GPs
- The Welsh government should consider having designated doctors at surgeries for mental health patients
- Ensuring arrangements are in place to monitor patients' medication
Despite the report's conclusion, Ms Menzies' sister Samantha said she believed more could have been done to prevent the incident.
She said the family and Tvrdon were let down by mental health services who should have done more to manage his condition.
"The report shows the consistency between him not taking medication and him relapsing," she said.
"If this was monitored I truly believe that he wouldn't have done it."
The agencies involved have accepted the report's recommendations.
Adam Cairns, chief executive of the health board, said: "While the review has acknowledged that it was difficult to see how this tragedy could have been prevented we do accept that, with hindsight, there were things that all agencies involved could have done better."