Last updated at 14:07 GMT, Friday, 27 November 2009
A health watchdog says the actions of a man with paranoid schizophrenia who stabbed a vicar to death in 2007 could "not have been predicted".
Geraint Evans, now 26, was detained indefinitely for killing Father Paul Bennett, 59, outside his vicarage at Trecynon, Aberdare, south Wales.
Health Inspectorate Wales (HIW) found his mental health was not assessed after an earlier self-harm incident.
The Bennett family's MP said they felt "let down" by the failings.
The report states that had Evans received a full assessment after self-harming, a diagnosis of psychosis could have been made, and treatment begun.
"Had he received such treatment over a period of time and responded adequately, the risk of his committing an act of violence or homicide might have been reduced," said the HIW.
But it accepts that the mental state of 'Mr D', as Evans is referred to in the report, "was never fully known to any medical services".
The HIW was ordered to carry out an investigation by the assembly government after the killing on 14 March 2007 outside the vicarage at St Fagan's Church in Trecynon.
Father Paul, who was profoundly deaf, was attacked as he went to put the rubbish out. His wife Georgina, hearing his screams, went outside to see Evans on top of her husband, attacking him.
Evans, who was obsessed with the devil, was detained indefinitely at a high security psychiatric unit for manslaughter on the basis of diminished responsibility at Cardiff Crown Court the following October.
Judge Nicholas Cooke QC said it was the "brutal killing of a wholly innocent man in an act of inhuman savagery.
"It was a killing as cruel as is possible to contemplate."
The court heard Evans suffered from paranoid schizophrenia and a personality disorder, and had used cannabis and inhaled lighter fuel since his early teens.
Undiagnosed
He was obsessed with God and the devil and fixated with religion and knives.
He was a subscriber and contributor to satanic websites using the pseudonym Jack Blade where he declared: "I am Satan."
But the findings of the report published on Friday said the case highlighted failures in services to "proactively engage" Evans' and his family, while he was a child and adolescent.
"Little support was offered by local authorities to Mr D's mother despite her requests," states the HIW.
The report found he went to accident and emergency in July 2006 after a self-harm incident but walked out due to a 40 minute delay for mental health assessment, and no follow-up took place.
It said there was "ambiguity regarding the level of concern" and lack of detailed records over the 2006 incident.
Chief executive of HIW, Dr Peter Higson, said: "The death of Father Paul has had a significant impact on his family and on the local community.
"It is clear that Mr D's mental health problems had gone undiagnosed and untreated for some time.
"While the homicide of Father Paul could not have been predicted, had Mr D received appropriate care and treatment the risk of him committing an act of violence or homicide might have been reduced."
The HIW also reviewed the role of the ambulance service to the stabbing.It found that Father Paul's wife had initially been asked to check her husband by 999 call handlers, despite Evans' still being present, armed with a knife.
It also revealed that there was a delay in identifying the correct address during the 999 call, and that paramedics made no attempt to resuscitate Father Paul.
In relation to the later involvement of services offering support to Father Paul's family, the HIW states: "There is a lack of formalised health or social care arrangements in place in relation to the wider community to respond to traumatic incidents of this kind which impact on a community."
The HIW's Dr Higson added: "For Father Paul's widow the tragedy has been compounded by her experiences following his attack and we have made recommendations in our report that are aimed at ensuring the matters highlighted by her experiences are addressed."
After the health watchdog inquiry was announced, Evans' mother Caroline said he was "devastated" by what he had done.
She said: "He was hoping rather than taking someone else's life, he would have died.
"He knew he was ill, more than anyone else or myself. He just kept holding it in and it got worse."
Chief executive of Cwm Taf Health Board Margaret Foster said they accepted in full the findings and were acting on the recommendations.
"Although Geraint Evans' mental state was never fully known to any medical services, there were clearly shortcomings in a range of services over a number of years," she said.
"On behalf of all the agencies involved, I apologise unreservedly for these."
'Let down'
In addition, Ms Foster said they were "deeply sorry" there was a delay in offering the appropriate support and counselling to Mrs Bennett following her husband's death.
Ellis Williams, director of social services at Rhondda Cynon Taf Council, said the authority was committed to "addressing the challenges" identified in the report.
Speaking on behalf of Mrs Bennett and her daughter, Cynon Valley MP Ann Clwyd said: "Unfortunately it shows, once more, that society is being let down by failings of our social services and health authority.
"How many more innocent people must lose their lives in the most horrific circumstances before these organisations begin to realise the consequences of their inadequate actions?
"How many more times must must we hear the words 'failed to follow up', 'opportunities missed' and 'poor communication'?
"Paul died a horrific death and I can still hear his screams of agony."
Speaking on behalf of the family, she added that while the police had conducted an internal review into their own response, that had not been openly reported.
Ms Clwyd said it took officers 10 minutes to arrive at the scene despite the station being just one mile from the vicarage and receiving a report that an armed man was on the loose.
She said that had Evans not stayed at the scene of his own accord until police arrived, it was unknown what "carnage" could have ensued.
She said the family hoped Health Minister Edwina Hart, who commissioned the report, realised the sacrifice Fr Bennett had made to learn the lessons announced today.
Friday, November 27, 2009
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