Holiday handed himself in to the care of a secure unit, but the following month a social worker let him back out into the community. This was a “missed opportunity” to have him sectioned, according to the report, which was written by the region’s strategic health authority, NHS Yorkshire and the Humber.

And the decision should not be made by one person. It should be made by a team and there should be a senior psychiatrist signing off on it.

Holiday missed his fortnightly dose of anti-psychotic drugs the day before the killing because he had not been home when a nurse called. He went on to steal a 10-inch carving knife from a store and was captured loitering in the street, as if waiting for someone to pass by.

One of the main reasons for community treatment orders is so that this does not happen. In high risk people a protocol (legal in NZ, but the UK is full of idiots making the life of both the mad and mad doctors miserable) is to admit to hospital briefly: we can and do use the police to bring people back for their injections.

If you miss your meds you can relapse. About 90% of people with schizophrenia who stop their meds will relapse. And being psychotic is very bad for your ability to cope in most people. In a few, very few, it leads to them being quite dangerous, which is why compulsory treatment exists.

He turned off into Wellsted Street, where his path crossed with Miss Stevenson, who had just left her home.

Holiday walked past her, turned and stabbed her once in the back, piercing her heart and leaving her bleeding to death. He then walked home calmly. Police tracked him down from CCTV images and Holiday admitted manslaughter on the grounds of diminished responsibility. He was ordered to be detained indefinitely at Rampton Hospital.

The report found that Holiday had been treated in at least five mental health units and was sectioned under the Mental Health Act on at least two occasions, but had a habit of escaping.

Known to be high risk. It would be interesting to see if there had been a review panel before all this.

Mr Snowdon apologised to the family of both Miss Stevenson and Holiday for the distress caused to them. He said the trust took the report “very seriously” and lessons had “already been learned”.

The NHS trust and clinicians should have acknowledged distress and that this was a tragedy from the beginning. That is not an admission before a court of law: that is being human and good care.

via NHS trust admit catalogue of errors let schizophrenic kill pregnant woman – Telegraph.