A mental health trust has been criticised after it said it was difficult to see how it could have prevented the murder of a seven-year-old girl by one of its patients.
Emily Jones was stabbed to death by Eltiona Skana in front of her parents in a Bolton park in March 2020.
Skana, 32, admitted manslaughter on the grounds of diminished responsibility and was given a life sentence with a minimum term of 10 years and eight months.
After Emily's death, Greater Manchester Mental Health NHS Foundation Trust (GMMH) - who had been treating Skana - conducted an internal review and said it was "difficult to see how this incident could have been prevented".
But NHS England has now disagreed with GMMH's assessment, saying there was not 'sufficient analysis' to justify their conclusion.
Its own investigation found Skana, who has paranoid schizophrenia, was "potentially dangerous when unwell" and that "it was clear by 2017 that [she] presented risks to others when she was ill, but not when she was well."
And while Skana "showed varying degrees of compliance... it was also clear that she became unwell when she was not taking medication as prescribed."
The report said: "Our most important finding is that the trust's understanding of risk concepts was poor."
Emily had been riding a scooter to meet her mother in Queen's Park when Skana sprang from a bench, grabbed her and slit her throat with a craft knife she had bought that morning.
Skana was well-known to mental health services and had been under the care of a community nurse who would regularly check in on her.
NHS England investigators found that GMMH's understanding of the risk that Skana posed to others was poor.
They also found that Skana had "a history of ambivalence around medication", and that she became seriously unwell and 'dangerous' when she had not taken it.
They said the risks attached to Skana failing to take her medication should have been clear following a series of incidents in 2015 and 2017.
In July 2015, Skana - who the report refers to as 'Ms A' - was detained under the Mental Health Act after being found holding a knife outside her home while shouting at an elderly neighbour.
While on an acute mental health ward, she was diagnosed with "acute schizophrenia like psychotic symptoms".
The NHS England report states: "It was clear from the incident in 2015 that, when unwell, Ms A posed a risk of violence.
"This was well understood by those who treated her in hospital in 2015. However, insufficient attention was given to this risk subsequently."
Skana was sectioned again in early 2017 after hitting her mother over the head with an iron during a vicious attack.
The review also provides details of another incident that happened while Skana was a patient on the mental health ward.
After absconding from the hospital, she tried to get hold of a knife before visiting a friend's house and asking to see their teenage daughter.
Skana was eventually discharged and came under the care of community treatment teams.
But in August 2019, the report found that Skana switched from injected medication to tablets, which made it harder to monitor whether she was taking her medication.
The review found Skana's care co-ordinator was not consulted and did not agree with the decision.
The report said it was not certain whether the consultant psychiatrist who authorised the switch 'properly understood' the risk involved.
At the time, Skana was not deemed to be a high-risk patient.
Skana's care co-ordinator went on sick leave for a month in January 2020.
After she returned to work, she saw Skana on 11 March - just over a week before the attack on Emily.
The notes from that meeting were not entered into the service's systems until much later, with the nurse explaining that she was about to go on holiday so had prioritised writing up the notes of the patients she was 'most worried about'.
Investigators said it was 'understandable' that the care co-ordinator had failed to spot signs that Skana was on the verge of a relapse as she often did so without warning.
A few days after the meeting, a member of Skana's family went to stay with her and saw her cutting her medication in half.
The report said that in the weeks prior to the incident, Skana had only taken half of her medication due to her experiencing side-effects.
No one at GMMH was found to be aware of this.
The review concluded that the trust's policy and documentation placed too much emphasis on how patients presented on a given day, rather than their underlying risk profile.
It added: "This focus on the ‘weather rather than the climate’ was at the heart of the trust’s failure to properly understand the unchanging risk that Ms A posed."
The review included several recommendations for the trust, including reviewing its risk policy 'to ensure that static risks are identified, and realistically assessed, and unnecessary weight is not given to dynamic factors'.
Emily's father, Mark Jones, has been heavily critical of the mental health services and slammed GMMH's internal review into Skana's treatment after it emerged last year.
Neil Thwaite, Chief Executive of Greater Manchester Mental Health NHS Foundation Trust (GMMH) said: "The Trust Board of Directors continue to send our deepest sympathies to everyone who loved and cared for Emily.
"We accept the findings of the external review into the tragic incident.
"We note the recommendations highlighted in the report, which will be actioned as a highest priority, and regularly reviewed.
"We recognise this will never change what happened and our thoughts remain with everyone affected by this devastating event."