'Missed chances' in care of Grimsby mother-to-be's killer
A man killed a woman and her unborn baby after several missed opportunities in his care and treatment by mental health services, a report has found.
Claire Wilson, 21, and her baby died in 2009 after she was stabbed in the back in Grimsby, North East Lincolnshire.
A report said Alan McMullan was left unmonitored after mental health services lost touch with him.
The report and the body in charge of mental heath care at the time said the death could not have been prevented.
Miss Wilson and her baby died in hospital after the attack in June 2009.
The independent report for NHS Yorkshire and Humber said McMullan, was assessed three times under the Mental Health Act and admitted to hospital twice in 2008, after handing himself into a police station armed with a knife and claiming voices were telling him to harm or kill people.
He was left unmonitored in the community after mental health services lost touch with him when he was discharged from hospital for the second time, the report said.
McMullan, who was jailed for life in 2010 for the murder, never received a full psychological assessment and the report said systems failures meant information about his risk level was not shared between agencies.
The report said the murder could not have been prevented, however elements of McMullan's care and treatment by North East Lincolnshire Care Trust Plus (CTP) could have been better.
It said: "We identified problems within the organisational processes but we found no causal link between these problems and the tragedy of 2009. Many substantial improvements have since been introduced."
McMullan, who was 53 at the time, was described as being calm and pleasant with no history of violence, but the report found that factors suggesting he was a higher level of risk were not taken into account.
Dr Peter Melton, speaking on behalf of the CTP, said: "We would like to reassure both the family of Claire Wilson and the wider public that everything was done to ensure our mental health services were, and continue to be, safe and of the highest quality.
"Incidents like this are thankfully very rare and as has been previously stated were not as a result of the care Mr McMullan received."
Kevin Bond, chief executive of Navigo, which now provides mental health services in North East Lincolnshire, said assessments of McMullan nearly a year before he murdered Miss Wilson did not find any symptoms associated with mental health problems.
He said: "I wish we were able to answer the most key question that has been often asked, as to why this man did such a terrible thing. Sadly, we cannot."