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The death of a woman who was killed by a fellow patient she met while receiving treatment in Whitchurch Hospital may have been prevented if services had realised the risks he had posed, according to a damning report.

Karen Welsh, 52, a kidney nurse from Thornhill, Cardiff, died of injuries to her head and lacerations to her wrists and was found at her home by police on March 2, 2010.

Ms Welsh was killed by John Michael Constantine, who suffers from paranoid schizophrenia, after befriending him in 2009 while she was receiving treatment for depression.

Constantine, who was found guilty of manslaughter on the grounds of diminished responsibility in March 2011, had been staying at Ms Welsh’s home from February 23, 2010, after moving himself out of a YMCA hostel.

He has now been detained indefinitely under the Mental Health Act.

A highly critical report published today by Healthcare Inspectorate Wales (HIW) raises concerns about the care and treatment provided to Constantine, who had been in regular contact with both health services and the probation service.

It says there were missed opportunities to diagnose him with paranoid schizophrenia after Constantine, who had a violent history, was initially diagnosed with personality disorder during his 12 days in Whitchurch Hospital in May 2009.

Constantine was released from the hospital without any follow-up planned from mental health services.

Six months after his discharge, he arrived at A&E following an apparent suicide attempt, and told staff he was living a Tresillian House homeless shelter, but felt if he stayed there, he would “kill someone”.

He was assessed by the mental health team in the A&E department but was told that he showed no psychotic symptoms, despite claiming he kept hearing and seeing ‘spirits’.

Constantine, who is referred to in the report as Mr J, became aggressive wanted to be admitted to hospital and threatened to commit suicide when he was told that he would not be referred.

The police were alerted, but despite an arrest warrant being in place for a breach of bail from a previous offence, police said they had no record of this and no arrest was made.

In January 2010, Constantine handed himself in, and as part of his bail conditions he was told to reside at a YMCA hostel.

However, he had trouble there and requested his conditions to be changed so he could reside at Ms Welsh’s address. He was told this would need to be approved but Constantine made the move despite this.

On March 1, 2010, various attempts were made by the probation service to telephone Ms Welsh to approve the request, not knowing Constantine had already moved in, but there was no answer.

Police were alerted when mental health staff became concerned that Ms Welsh, who had been on home leave from Whitchurch Hospital, had not returned on March 2.

Her body was discovered and Constantine, who had fled the scene, handed himself in on March 3.

Following his sentencing, he was diagnosed as suffering from paranoid schizophrenia.

The HIW report raised concerns over the adequacy of care and treatment given to Constantine and the confusion of the arrest warrant, which caused a number of missed opportunities to re-arrest him.

The report also raises major concerns about the communication between difference agencies.

Following the report, Ms Welsh’s daughter, Joanne, said: “It is extremely upsetting to hear the conclusion that my mother could still be alive today had it not been for misdiagnosis, failures in communication between the relevant agencies and a lack of mental health awareness.

“Unfortunately, these failings meant that a very dangerous and unwell man was let down and allowed to commit such a devastating crime. I sincerely hope that all parties involved will take the recommendations made very seriously and make the necessary changes to prevent other innocent lives being lost.”

Chief Executive of HIW Dr Kate Chamberlain said: “Our review highlighted concerns in relation to the assessment and monitoring of Mr J by statutory agencies. In our report of a homicide committed in October 2005 we made a recommendation that the Welsh Government should ensure that the commissioners and providers of mental health services in Wales examine the provision for assessment and treatment of those suffering from personality disorder with a view to putting relevant services in place.

“It is therefore disappointing that Mr J’s initial diagnosis of personality disorder resulted in him being discharged with no care plans or arrangements for further assessment and treatment being put in place.”

Cardiff and Vale University Health Board has apologised to Ms Welsh’s family.

Director of nursing, Ruth Walker, said:“The three years that have passed since these tragic events took place in no way diminishes their enduring impact and we would like to emphasise our sincere apologies and condolences to the victim’s family.

“The unpredictable nature of mental health disorders means that it is not always possible to foresee every potential eventuality and this is recognised by Health Inspectorate Wales in its report.

“Events like these are rare but we understand how important it is that all agencies involved in the delivery of mental health services must continually strive to work more closely together.

“It is clear that communication between statutory agencies fell short of expectation, and, ultimately, both patients were let down by that failure, with tragic consequences. We have worked to correct many of the deficiencies highlighted in the HIW report.

“As a Health Board, we fully accept the recommendations outlined in the HIW report and are working with partners to address any remaining issues raised by HIW as a matter of urgency.”

Chief Medical Officer for Wales Dr Ruth Hussey said that many of the findings of the report had been of concern.

She said: “My thoughts are very much with the families of those affected by this serious and deeply distressing case.

“While risk can never be eliminated entirely, it is vital we do everything possible to identify any shortcomings in care and put in place measures to reduce the risk of such tragic incidents happening again.

“In this complex case, there were several key findings of concern. The Welsh Government expects the local health board involved to work with other partners to take the appropriate actions and learn from this tragic case.”

A statement from the probation service said: “Karen Welsh’s death was an appalling tragedy and we offer our sincere and heartfelt sympathies to her family and friends.

“We would like to reassure the public that all of our professional practice around mental health training and referrals is continually reviewed and developed as part of our ongoing commitment to public protection and Karen Welsh’s tragic death has served to highlight the importance of this.”

South Wales Police said:“South Wales Police conducted a thorough and professional investigation into the tragic death of Karen Welsh in March 2010 which led to the conviction of John Michael Constantine for manslaughter. Our thoughts remain with Karen's family.

“The Healthcare Inspectorate Wales report makes two recommendations for police to review policies and processes for the management of arrest warrants. These reviews have already taken place and we are confident that our systems are robust to ensure individuals who are wanted on warrant are dealt with effectively.”