A devastated mum whose son killed a stranger in the street just days after being released from a psychiatric unit has demanded an apology from NHS health bosses.
David Fleet, 20, stabbed 71-year-old Lewis Stone from Staffordshire in a random attack near the family home in the Welsh village of Borth, Ceredigion in 2019.
He died in hospital from his injuries three months later.
A trial at Swansea Crown Court later the same year heard that Fleet was suffering from an episode of schizophrenia when he approached Mr Stone on the banks of the River Leri while he was walking his dog.
Fleet, who had a history of mental illness but was being managed in the community, was heard by his brother that morning apparently speaking to himself in his bedroom, saying “I’ll be there now”.
He then left the house and walked towards an amusement arcade in the village dressed in a hoodie, reports Wales Online.
His mother Sharon Lees is now calling for Hywel Dda University Health Board to issue a public apology to both her and the victim's family, after an unpublished report seen by BBC Wales Investigates suggested she had warned them over her son's mental state only three days before the incident.
She says the board had since told her in a private letter that changes had been made to its mental health services following the killing - but believes this does not make amends for what happened.
Sharon told BBC Wales Investigates: "It has resulted in two families being devastated. Ultimately this could, should have been prevented. There were enough warnings there.
"It’s really important for not only us, but the Stone family to have a public apology….because of his illness and the lack of care he received it only feels justified that he also receives an apology because the health board failed him which in turn then failed his victim’s family."
A copy of the report seen by the show also shows that mental health staff did not make scheduled contact with David Fleet on the day before the incident, and that he had not received a new dose of his anti-psychotic medication.
At the end of the trial in 2019, Judge Paul Thomas described the attack as a “horrific event” but said he could not send Fleet to prison due to his medical condition. He told the court: “What happened could not have been foreseen. It was a catastrophic event.
"Mr Stone was at the wrong place at the wrong time.”
Mr Stone’s family described Fleet as a "monster" and said at the time that they found no excuse or forgiveness for what he did.
But Sharon believes more information about what led up to the attack should have been shared with the Stone family, and says the findings of the report need to be shared with NHS boards across the UK to "prevent tragic cases like this from ever happening again".
Responding to the Mirror's requests for comment, Mandy Rayani, Director of Nursing, Quality and Patient Experience for Hywel Dda University Health Board said: "We are unable to comment upon any individual cases as we have a duty of care and duty of confidentiality to our patients.
"In the event of a serious incident we have robust processes in place for reviewing the incident internally, identifying any issues and, where appropriate, preparing an improvement plan to prevent such an occurrence in the future.
"We regret any such incidents, and always seek to learn from them. We endeavour to engage with those directly impacted whenever there is cause for concern.
"For the most serious incidents we would conduct a clinical review of the incident. Our aim is to identify learning points and to have the relevant information available that will explain what, why and how the incident happened.
"In accordance with national guidelines we will then submit a Serious Incident Report to Welsh Government or National Reportable Incident to the NHS Wales Executive, depending on the policy requirements at the time of the incident."
- BBC Wales Investigates, BBC One Wales on Monday at 8pm. It will also be available on BBC iPlayer
