Report critical of killer's care

Christopher Devine admitted he had stabbed Sandra Vincent

The care received by a mentally ill patient before he stabbed a 56-year-old woman to death has been criticised.

Christopher Devine, 23, from Rhyl, Denbighshire, killed Sandra Bowring (also known by her maiden name Vincent) after they met at a psychiatric unit.

Healthcare Inspectorate Wales (HIW) said steps which would have made the killing unlikely were not taken.

The North Wales NHS Trust apologised and said a review had been carried out making services "much safer".

The Conwy and Denbighshire adult mental health and social care partnership said it accepted the findings of the HIW report.

In its report, HIW said: "While it cannot be guaranteed that Sandra Bowring's killing could have been prevented, steps that may have rendered the homicide unlikely were not taken."

"There are important lessons to be learned from this tragic case to ensure that mental health services are better able to minimise the risk of similar incidents in the future," said HIW chief executive Dr Peter Higson.

North Wales NHS Trust chief executive Mary Burrows said she wanted to "publicly apologise" for what had happened and said she was "deeply concerned" about the report's findings.

We must all resolve to learn from these situations... Ann Lloyd, NHS Wales chief executive

Devine stabbed Ms Bowring at least five times in October 2006.

She was able to tell who had attacked her, but died two days later.

Devine, who had a long history of behavioural problems, had initially denied murder but changed his plea during a trial at Caernarfon Crown Court in 2007 and was jailed for life.

The pair had met while they were patients at a psychiatric unit at Ysbyty Glan Clwyd, Bodelwyddan in 2005.

The trial heard she had become "strangely, deeply attracted" to him and one of her relatives had said she was "obsessed" with him.

But Devine, the court heard, had previous convictions for violence involving the use of knives.

The HIW report said he had "a personality disorder and complex needs" and had "difficulty accessing services..."

It went on: "... the resources available were not robust enough to provide the intensive support he required to manage his complex and difficult behaviour".

Serious assault

Amongst other findings the report concluded that "once diagnosed with a personality disorder there was a belief that mental health services could do nothing for [Devine]".

There were also failings in the approach of local services to assessment and risk management.

In August 2006, following a case of deliberate self harm, Devine requested that he should be detained under the Mental Health Act, but was told that it would be inappropriate.

The report also said Ms Bowring had reported a serious assault at the hands of Devine to North Wales Police but it was not followed up.

When she was admitted to the psychiatric unit on 21 September last year she told nurses she had suffered a broken nose and later reported the incident to police.

But on 24 September she was still awaiting a visit from officers and police later said they had no record of her complaint.

However, since the completion of the review police have now confirmed they did receive a call from Ms Bowring and the matter is being investigated.

'Much safer'

Jill Galvani, director of nursing and patient services for North Wales NHS Trust, said: "First I would like to say that we are sorry for what happened and would like to extend our deepest sympathy to the families involved in this tragic case."

She said a review had been carried out immediately after Ms Bowring's death and as a result of measures taken the trust was confident its services were now "much safer".

Ann Lloyd, NHS Wales chief executive and head of the Welsh Assembly Government's health and social services department, said: "We must all resolve to learn from these situations and identify changes needed to reduce the risk of such events happening again.

"Local health and social service bodies have already prepared action plans to take action to reduce risk in the community.

"They are taking this tragic event and its aftermath very seriously indeed. Lessons must be learned and changes implemented."