A killer who stabbed a friend and dumped his body in the River Avon had been assessed by psychiatrists as ‘much improved’ three days before the frenzied attack.
James Lee Bible, then 20, killed Alan Clarke, 59, as they walked alongside the river in Salisbury in April 2008.
He was one of three patients being treated by the Avon and Wiltshire Mental Health Partnership NHS Trust in 2008 who went on to commit chilling killings.
Independent reports published yesterday into the homicides in Wiltshire, Weston-super-Mare and Bristol revealed a series of missed opportunities to intervene and inadequate communication and partnership between different agencies.
But they stopped short of identifying “direct causal factors” between the care and treatment the three men received and the killings.
James Allen was convicted of murdering neighbour Terry Hall in Weston-super-Mare during a row over a discarded washing machine.
Allen, a recovering drug addict, hit Mr Hall seven times over the head with a baseball bat, breaking his skull. He died in 11 days later.
The following year, Allen was jailed for life and ordered to serve at least ten-and-a-half years by a judge at Bristol Crown Court.
Liam Churchley was jailed alongside his mother, brother and cousins for the killing of Alan Riddock outside a pub in Bedminster, Bristol, while Bible was detained indefinitely for stabbing Mr Clarke.
All three had been receiving treatment for a variety of problems, including addiction and psychiatric disorders.
And yesterday Julian Hendy, whose father Philip was murdered in Bristol in 2007 by a man receiving treatment from the trust, demanded that it “learns lessons”.
Mr Hendy said: “We’ve heard the same problems time and time again from these inquiry reports.
“Each time they say ‘things are different now’ until it happens again, so they really need to show that they have learned the lessons.” The reports highlighted aspects of care that could have been better, but each concluded that it would “not be reasonable” to assume that these had an impact on each incident. Of 28 recommendations, 22 relate to the trust.
Medical director Dr Arden Tomison said: “I would like to offer again our condolences to the families and friends of all the victims and to those who have been affected.
“Across the trust our staff deal with individuals whose complex needs, behaviour and reluctance to be helped can make delivering effective care support very difficult.
“The decisions our staff make about the care and support provided to service users are informed by the best clinical understanding of their individual clinical needs.
“As the independent investigations highlight, aspects of the way we worked in 2008 could have been better – for example in the way we engaged with families, in collaborative working, in risk management, in sharing information and in care planning – and these are handled very differently today.
“But the investigation teams acknowledge that even if different approaches had been followed, it is not reasonable to assume that the outcomes would have been different.”
The findings were considered at a meeting of the NHS South of England’s patient and care standards sub-committee.
Only relatives of Mr Hall attended. Deborah Hall, his partner of 18 years, said in a statement: “Terry died unnecessarily. Terry does matter and we have waited nearly five years for some answers. We hope that this report goes some way in protecting innocent people.”