John Barrett walked out of hospital without being stopped

John Barrett repeatedly stabbed 50-year-old Denis Finnegan with a kitchen knife, after ambushing him as he cycled through Richmond Park, south-west London, in September 2004.

Despite his long history of mental illness and violent past, Barrett who was a voluntary patient in a secure unit at Springfield Hospital in south London had been given permission to walk around the hospital grounds for an hour.

But he discharged himself and left the hospital, going to buy a set of kitchen knives. The next day he killed the former banker in an unprovoked attack in Richmond Park.

It is a question of changing a culture which puts patient's rights ahead of those of their families and the community Marjorie Wallace, Sane

The inquiry, headed by mental health solicitor Robert Robinson, said too much emphasis was placed on Barrett's wishes and he was not assessed adequately.

Mr Robinson said: "There was a tendency to emphasise unduly the desirability of engaging with John Barrett co-operatively, rather than intervening against his wishes to reduce risk."

It has recommended a national evaluation of the mental health service to look at failings and say what systems should be put in place to ensure patients are monitored properly and effectively.

Warnings

Marjorie Wallace, chief executive of the charity Sane, said cases such as Barrett's were rare - around 40 murders a year are committed by people with mental illness - but the communication failures it exposed were not.

She said: "Yet again we have an inquiry that exposes the same lack of communication and supervision and the failure to protect patients and the public.

Denis Finnegan's family have welcomed the inquiry's conclusions

Sane analysed 69 inquiries into homicides involving a person with a mental disorder and found that in half of cases mental health professionals ignored the warnings of family and friends.

"It looks as if Denis Finnegan should never have lost his life had staff heeded the pleas of Barrett's former partner.

"It is not easy to know who is going to be violent. But if concerns are being raised by those around them, they should be listened to."

She added: "This is not just a question of changes to the law or of inadequate resources, it is a question of changing a culture which puts patient's rights ahead of those of their families and the community.

"It's about taking into account what might be therapeutic for the patient - but also the rights and the safety of others."

She said it was most often the patient's family whose safety was threatened, and it was rare a stranger was at risk.

Ms Wallace said there was a lack of resources in mental health service, as well as poor morale.

But she said: "It is only a small number of psychiatric patients who have a history of violence, so it is even more disturbing that someone like John Barrett is allowed to walk out of a secure unit without, it appears, taking into account the risk he posed to himself or others."

She called on people working in the mental health system to ensure they listened to people who raised concerns about patients, and ensured they communicated effectively with other staff in the service.

'Catalogue of errors'

Health Minister Rosie Winterton said the report made clear that the importance of clinicians assessing risk properly and then planning care accordingly.

"This is an essential part of patients getting the care they need, helping to keep themselves and others safe from harm. We are currently reviewing these processes nationally to directly address some of the concerns raised in this case.

"The Mental Health Bill, being introduced today, will also make it easier to ensure that people with mental disorder receive the treatment they need."

However the Barrett report said: "The remedy for what went wrong in this case lies not with new laws or policy changes."

And Claire Ashby, of the mental health charity Mind, said: "This was about systematic failures. It's not anything to do with a policy of legislation.

Barrett, who was jailed for life in March 2005 for the killing, had previously been detained at the hospital after injuring three people in a knife attack.

Barrett pleaded guilty to manslaughter on grounds of diminished responsibility and is now being treated in Broadmoor Hospital.