[bitontheslide]

The murder of a man by a violent schizophrenia patient "could have been avoided" had a medical tribunal been given complete information on his past, a report has concluded.

Jeffrey Barry stabbed neighbour Kamil Ahmad at their supported flats in Bristol in July 2016, hours after his release from a secure mental hospital.

Barry was detained after hearing voices and threatening to murder Mr Ahmad.

The report said the decision to release him had "tragic consequences".

A review by the Bristol Safeguarding Adults Board (BSAB) found that information sharing between Avon and Wiltshire Mental Health Partnership (AWP) and the psychiatric hospital where Barry was an inpatient "failed due to the absence of key personnel due to annual leave".

It said that systems "should have been robust enough" to have contingency plans for when "a key professional is absent from work".

Barry is now serving at least 23 years at Broadmoor secure hospital after being found guilty of murdering Mr Ahmad in a "savage and sustained" attack, in which he sliced off the Kurdish refugee's penis.

The judge described the failures leading to his release as being "nothing short of calamitous".

Because of bed shortages, Barry was moved from the Callington Road NHS psychiatric hospital to the privately-run Cygnet Hospital in Kewstoke, North Somerset.

He did not want to stay and asked for his case to be reviewed but his NHS care team were only given 24 hours' notice to compile their notes for the independent panel.

But the safeguarding report found the decision to discharge him had been "based on incomplete information" and had "foreshortened his compulsory treatment".

It said the mental health review tribunal had not followed the "recommendations of the professionals involved" or appreciated the "inherent risk" of his return to the supported flats.

The report also detailed a lack of face-to-face planning for Barry's release. Each of the agencies "recognised" this problem but the meetings "did not take place".

Chair of BSAB Louise Lawton said the report had "identified opportunities" which could have been taken to separate Mr Ahmad and Barry.

"Of particular consequence is the process by which [Barry] was discharged from a secure hospital on the day of Kamil's murder, how agencies worked together to coordinate care and assess risk, and opportunities to terminate [Barry's] tenancy at the housing provision," she said.

"Whilst nothing can make up for the loss that Kamil's family have suffered, I hope that the review's recommendations will help to safeguard other adults at risk of harm in the future."

Rebecca Eastley, from AWP, said it accepted the findings of the report "in its entirety".

"This was a tragic and brutal death and we are deeply sorry," she said.

"We are committed to doing all we can to prevent such an incident happening in the future."

https://www.bbc.co.uk/news/uk-england-bristol-44560171

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I really hope lessons are learnt.