Health bosses have said lessons need to be learned in the wake of a devastating hit-and-run rampage caused by a paranoid schizophrenic.
Matthew Tvrdon went on a journey of mayhem in Cardiff almost two years ago – killing a 31-year-old mother Karina Menzies and injuring 20 others across five locations in the Welsh capital.
The 32-year-old was detained indefinitely by a judge under the Mental Health Act last year.
During his court case, it emerged Tvrdon had a long history of mental health problems, and believed that fateful day that unconnected members of the public were out to get him.
Healthcare Inspectorate Wales (HIW) has published a report on the provision of mental health services Tvrdon received leading up to the tragedy.
The 75-page study made seven main findings, and revealed it was likely Tvrdon had not been taking any of his medication 12 months before the incident.
It also found when discharged by the Community Mental Health Team, there was “no discharge or contingency plan” in the event of him relapsing.
But HIW chief executive Kate Chamberlain insisted the events of October 2012 could not have been predicted.
She said: “Incidents of this type are extremely rare and the purpose of our investigation was to identify learning, to ensure mental health services are better able to minimise the risk of similar incidents in the future.
“HIW’s findings suggest it is unlikely this homicide could have been predicted and given the particular circumstances it is difficult to see how it could have been prevented.
“However, recommendations have been made to learn from the actions leading up to this incident.
“We need to reassure all those individuals touched by the tragic events such as these that action can be taken to reduce the risk of such events happening again.”
HIW’s said Tvrdon – who was referred to as “Mr L” in the report – had a “stable upbringing” and there were no behavioural problems reported in his childhood.
But he began showing signs of mental illness while at university, culminating in his studies finishing early.
In 2003, he was admitted to Whitchurch mental hospital in July 2003 after showing signs of psychosis.
Over the next four years, he was admitted to hospital under the Mental Health Act on four separate occasions after suffering relapses.
In July 2007, he was arrested by police outside a bank in Usk with an imitation gun and wearing latex gloves and was described as “clearly agitated, aggressive and visibly shaking”.
The report said it took three officers to forcibly detain Tvrdon, even after the use of CS spray.
But HIW said it found Tvrdon had been “successfully treated” and had a “controlled” discharge involving the Crisis Resolution and Home Treatment team.
“Mr L responded positively to his medication regime by making a good symptomatic, functional and social recovery,” the report said.
“Nevertheless, the review team note some concerns relating to the organisation of Mr L’s discharges from hospital.”
The report said around this time it was clear Tvrdon’s reluctance to comply with his medication regime had caused episodes of deterioration in his mental health.
“We know from our review, that from approximately October 2011 until the incident in October 2012 it was likely Mr L was not taking any of his medication,” the report added.
On October 19 that day, Ms Menzies, was hit by a white van driven by Tvrdon while walking with two of her children outside Ely fire station.
It later emerged Ms Menzies had pushed them out of the way before the van hit her.
Tvrdon later admitted manslaughter on the grounds of diminished responsibility.
He also admitted seven counts of attempted murder and other charges including three counts of grievous bodily harm with intent during the incident which took place over eight miles of the city as parents were on the school run.
Cardiff Vale and University Health Board insisted it had accepted and acted upon HIW’s recommendations.
Chief executive Adam Cairns said: “I would like to offer our sincere sympathies to Karina’s family and everyone affected by these tragic events.
“With hindsight, there were things that all agencies involved could have done better.
“We have taken steps to make sure mental health services are appropriate, safe and manageable and we have completed a review of those practices and services and agreed measures for improvements.”
Despite the report’s conclusion, Ms Menzies’ sister Samantha believed more could have been done to prevent the tragedy.
She told BBC Wales that her family and Tvrdon had been badly let down by mental health services who should have done more to manage his condition.