Manchester Health Trust failed to warn of killer's risk
A health trust failed to warn a man murdered by his former partner that he was at risk, a report has revealed.
Brian Maddock, 44, had previously told his psychotherapist he planned to kill Michael Naylor with a knife he kept under his bed.
The report by NHS England said the risk posed to Mr Naylor by Maddock had not been assessed, before he was stabbed to death at their Manchester home in 2010.
Manchester Mental Health NHS Trust has apologised to Mr Naylor's family.
Speaking after the report's release, Mr Naylor's sister, Barbara Venner, said she believed the trust's failings were responsible for her brother's death.
"I believe that Michael would still be here today had he been told about the threat to his life," she said.
"Michael was very, very close to me and he valued his safety very carefully.
"If he'd have known that his flatmate was planning to kill him in such an horrendous way he would have left immediately."
She added that she wanted a change in the law to require mental health professionals to inform the police or the victim of such a threat, if they are told by one of their patients.
The report on Maddock detailed how the Trust became aware that he was violent when drinking and that he had previously stabbed another partner with a fork.
Investigators said his care was not coordinated properly, despite tests showing he was suffering from post-traumatic stress disorder, anger problems, obsessive behaviour traits and psychotic episodes.
This indicated that some sort of serious incident was foreseeable, clearly showing that the risk he posed should have been brought to the attention of Mr Naylor.
But the report concluded Maddock could not have been prevented from acting the way he did.
Mr Naylor's body was found at the house in Hambridge Close, Cheetham Hill, in November 2010.
But the review said "no causal link could be made between any act or omission on the part of the Manchester Mental Health Care NHS Trust and the killing of Michael Naylor".
It concluded: "Brian Maddock retained full capacity and was found to have no abnormality of mind sufficient to have influenced either his thoughts or actions."
Dr Jaswinder Bamrah, of the mental health trust, said a thorough investigation had been carried out after Mr Naylor was killed.
As a result, a "number of actions to improve processes around the care provided to patients presenting in a similar way" have been undertaken, he said.
He also said there had been "significant improvements" to risk-monitoring and reporting, including the introduction of additional training and the establishment of a high level incident panel.
Julian Hendy, from hundredfamilies.org, a support group for families of victims killed by people with mental health problems, said all mental health services needed to learn "effective lessons from Michael Naylor's death".
"In this case it was known that a serious incident was likely to happen, yet like so many other cases, there were clear failings to plan care properly, to do proper risk assessments and to share information appropriately.
"There is little evidence that mental health services learn from these tragedies, and so the same mistakes keep on being made, and wholly avoidable deaths keep on occurring."
Maddock was convicted of Mr Naylor's murder in May 2011 and jailed for life. He must service a minimum of 15 years before he can be considered for parole.