Paul Khan was being treated in the community

Paul Khan, 35, from Cardiff, travelled to Prestatyn in 2003, where he killed 72-year-old Brian Dodd.

Khan, a paranoid schizophrenic, was being treated in the community after carrying out a knife attack in 1996.

The report was carried out for Cardiff Local Health Board (LHB), which is now overseeing a review of all mental health patients in the community.

Khan admitted manslaughter on the grounds of diminished responsibility and was jailed for life in October 2003.

After the case, the Welsh Assembly Government ordered Cardiff LHB to carry out an investigation into the case.

An independent health service research organisation, appointed by Cardiff LHB to carry out the investigation, has identified failings made by organisations involved in Khan's care.

Brian Dodd suffered at least 28 separate injuries

The report said that the health authorities failed to follow the safeguards they had put in place to keep control of Khan if his illness worsened.

Khan disappeared the day before Mr Dodd's death, but his parents were advised to inform the police themselves.

In their conclusion, the report authors said: "The event was difficult to predict because of the lack of specific and measurable relapse indicators.

"The 12-hour missing rule was an important part of Paul Khan's risk management plan.

KEY FAILINGS Failure to meet conditions of discharge and aftercare Failure to monitor substance misuse Failure to inform the Home Office of admission to Whitchurch Hospital, April 2002 Failure to ensure medication was taken when in hospital Failure to apply agreed '12 hour missing' rule

"Although the offence had already been committed, the failure to implement the 12-hour rule resulted in a situation where Paul Khan was effectively out of the area without the instruction to recall him being considered or put in place."

The report also found a "failure to meet specified conditions of discharge and supervised aftercare" in Khan's case.

'Substance misuse'

It recommended that "That Bro Morgannwg NHS Trust and Cardiff and Vale NHS Trust give careful consideration to whether patients conditionally discharged into the community can be adequately managed in full time independent living or whether they should remain in supervised hostel accommodation".

The report also said that there was a "failure to monitor substance misuse as a condition of (Khan's ) discharge".

The murder took place near Ffrith beach festival gardens

Hugh Ross, Chief Executive of Cardiff and Vale NHS Trust, said there had been "some systems failures around communications" with the Home Office and other agencies.

He said: "We have reviewed our procedures, strengthened our staffing, worked closely with our partners in health and social care to try and make sure, as best we can, that something like this does not happen again."

He said a "misunderstanding" had led to the delay in reporting Khan's absence.

"The social supervisor whose job it was to do so was away and clearly no-one else took on the responsibility for doing it.

"Of course, by the time that we knew Mr Kahn was missing I'm afraid that Mr Dodd was already dead. Nevertheless it was a system failure."

Ann Lloyd, Head of the Welsh Assembly Government's Health and Social Care department said that as a result of the review Health Commission Wales had been asked to undertake an audit of discharge planning arrangements from medium secure units across Wales.

Mrs Dodd has called for a judicial inquiry into her husband's death

She said: "Both the assembly government and the organisations concerned will ensure that everything that can be done to reduce the risk of such an event happening again will be implemented in Wales."

A formal response to the review by the assembly government will be issued in the New Year.

Cardiff LHB added it was "already overseeing a prompt review of all mental health patients in Cardiff who are receiving supervised aftercare in the community."

Wendy Robinson, whose daughter was stabbed to death in 1993 by a former Broadmoor patient who was released into the community on a restriction order, commented on behalf of the mental health charity The Jane Zito Trust.

She said she felt very sad for both families involved but also very angry to know that "these things are still happening, that there are still failures of care within the community".

Knife attack

She said: "It is very difficult for families to cope with this, it is even more so when you think it could actually have been prevented.

She said: "It's happened in so many cases that the patient does not comply with the medication that they are supposed to take.

"If they don't turn up to take it, who is there to make sure they are there?

"Unfortunately, they can get on a bus, a train they can go anywhere, it is not just turning up at their home to say 'come along, you've got to come'.

Khan had been sentenced to an indefinite hospital order in 1996 after a knife attack on a man in a Cardiff library.

Stopped taking medication

But in 2000 a mental health tribunal ruled he could be treated in the community.

In March 2003, Khan, who had stopped taking his medication, drove to Prestatyn with his dog.

He arrived at the town's Ffrith Beach and attacked retired accountant Mr Dodd, who was walking his two dogs, with a large kitchen knife.

Mr Dodd suffered at least 28 knife blows to the head, neck and chest.

Days later, Khan was arrested in an altercation in Newport, south Wales.

He was jailed for life at Chester Crown Court in October 2003.