There were “clear shortcomings” in the treatment of a man with mental health problems who beheaded a British grandmother in Tenerife after being released from a hospital in north Wales.
A report into the killing of Jennifer Mills-Westley by Deyan Deyanov, a Bulgarian drifter, said the “likelihood of such an incident occurring might have been significantly reduced” had there not been failings in his treatment.
Twice in 2010, while visiting an aunt in Flint, Deyanov was admitted to the Ablett psychiatric unit, but he was discharged in October of that year after having been diagnosed as having no serious mental illness. According to the report from Healthcare Inspectorate Wales (HIW), doctors thought he was malingering to try to get accommodation.
He travelled to the Canary Islands and launched his attack on Mills-Westley, 60, the following May. The 31-year-old, who was a user of LSD and crack cocaine, is being held in a secure psychiatric unit in Spain after he was convicted of murder by a jury.
Betsi Cadwaladr University Health Board, which provides mental health services at Ablett, carried out an internal review and concluded lessons had been learned, but HIW was commissioned by the Welsh government to carry out an inquiry into the care of Deyanov after Mills-Westley’s two daughters, Sarah and Samantha, pressed for an independent review. They have claimed that a catalogue of failings by a number of authorities led to their mother’s death.
They said their mother would still be alive if staff had recognised that Deyanov had serious mental health problems.
In a statement, they said: “The Healthcare Inspectorate Wales report has highlighted a number of significant, basic medical best-practice failures. These failings are far worse than we had imagined.”
They continued: “We sincerely hope that our mother’s murder will not be in vain and that the Betsi Cadwaladr University Health Board will recognise the repeated shortfalls in the care they provide and act on the issues identified in this report.
“We cannot put into words the sense of betrayal we have experienced with our dealings with the health board. They have continued to prolong our pain by obstructing our pleas for truth and have become a faceless organisation hiding behind bureaucracy. The way they have treated our family has been appalling.”
The inquiry will refocus on the care and supervision given to potentially dangerous people with mental health problems. It comes as an inquiry is being launched into why Matthew Williams, who killed 22-year-old Cerys Yemm in a suspected act of cannibalism last week in south Wales, was apparently not given supervision or access to the drugs he needed to control his paranoid schizophrenia.
In September another damning report revealed that Matthew Tvrdon, a van driver who had paranoid schizophrenia, had been discharged from treatment without adequate follow-up care or supervision before he went on a hit-and-run rampage in Cardiff that left a mother dead and 20 people injured.
Julian Hendy, director of Hundred Families, a charity that supports loved ones of those killed by people with mental illnesses, said: “Our charity has studied very many of these health service investigations throughout the country and what troubles us is the failure of mental health agencies to learn lessons effectively from these tragedies – so that avoidable deaths keep on occurring and innocent people are losing their lives unnecessarily.”
The main findings of the Deyanov report are:
Several aspects of his care were not delivered to a sufficient standard, resulting in the formation of an inappropriate diagnosis and unsatisfactory aftercare arrangements.
There was a lack of effective multidisciplinary teamworking, in particular in relation to ward rounds, which resulted in a narrow breadth of information being available to make clinical judgments.
There existed a culture where a prejudiced view of Deyanov was fostered by some staff.
There was a lack of integrated patient notes, which hampered effective comparison, decision making and systematic monitoring and review of Deyanov’s clinical presentation and progress.
A greater level of engagement with the family of Deyanov would have assisted in developing a greater understanding of his background and history.
Discharge arrangements after both of Deyanov’s admissions at the Ablett psychiatric unit were unsatisfactory. It was unclear as to whether adequate steps had been taken to ensure due regard was given to his wellbeing.
Deyanov attacked Mills-Westley, a retired road-safety worker, in a shop near the beach at Los Cristianos, plunging a 22cm-long (9in) knife repeatedly into her neck. He then walked out carrying her head before being wrestled to the ground and arrested.
The killer had been detained on the island at least four times since January 2011 for violent offences. He was sectioned at La Candelaria hospital before being bailed in February 2011. A warrant for his arrest was issued three days before the killing but officers were unable to locate him.
The son of a communist apparatchik and factory owner, Deyanov grew up in the Bulgarian city of Ruse, which is known as Little Vienna. The family fell on hard times with the demise of communism and Deyanov’s father abandoned his two sons.
Deyanov drifted all over Europe, staying in Edinburgh, north Wales and Ibiza before arriving in Tenerife.
At first he worked selling timeshares on the island. But his erratic behaviour meant he could not keep a job for very long, and at the time of Mills-Westley’s death he was living rough in a crumbling beachside building where he created a disturbing quasi-religious shrine.
According to a friend who lived with him there, he showed interest in Bogomilism, a Bulgarian cult that believes the world was created by the devil. During his trial, Deyanov claimed voices in his head told him he was an angel of Jesus Christ sent to create a new Jerusalem. He said they told him to “kill, fight, hit and pray”.