Three major opportunities were missed to assess risks posed by a paranoid schizophrenic who repeatedly stabbed a woman in a supermarket, according to a report today.
Samuel Reid-Wentworth inflicted 21 stab wounds on Lucy Yates six weeks after being discharged from a mental health unit.
He spotted Miss Yates on a bus and followed her into a Somerfield store in Littlehampton before carrying out his attack, in September 2008.
Miss Yates, then 22, survived. Reid-Wentworth was charged with attempted murder and detained under the Mental Health Act. He is in Broadmoor Hospital.
Investigators Verita considered the care he had received from Sussex Partnership NHS Foundation Trust and said chances had been missed.
The first was when he was admitted to psychiatric services in August 2007, after assaulting two female strangers, each occasion with a weapon.
"The motivation underlying the assaults and the significance of his associated symptoms were never fully explored," the report says.
The second opportunity was when he was transferred to the rehabilitation and recovery unit after five months on the acute admission ward.
The report says: "Assessment of risk was incomplete and the potential seriousness of the two assaults on the women prior to admission was still not fully appreciated."
In the report, Reid-Wentworth is called 'Mr Z".
The third opportunity was when he was re-admitted to the acute mental health ward after the re-emergence of psychotic symptoms including thoughts of killing people.
In addition to the three "pivotal points" where opportunities were missed, there was also little evidence of staff attempting to establish a relationship with his mother, who was a very important part of his future care plan, the report says.
"In spite of Mr Z's extensive periods of leave to his mother and older brother's addresses neither was approached for their views as to the success or otherwise of these arrangements."