Mary Griffiths bolt-gun murder 'not predictable'
An inquiry into the care of a "delusional" murderer, considered for sectioning shortly before killing a woman with a bolt gun, has found the killing could not have been predicted.
Mary Griffiths, 38, of Bury St Edmunds, Suffolk, died early on 6 May 2009 following the attack.
John McFarlane, 40, was jailed for life for the murder in November 2009.
The strategic health authority inquiry found McFarlane had no history of violence.
Nine people who were under the care of the Suffolk Mental Health Trust, including McFarlane, went on to kill over the last two years.
Dr Hadrian Ball, medical director at the Suffolk Mental Health Trust, said: "Suffolk Mental Health Trust has experienced significant difficulties, particularly in 2009 and 2010.
"These difficulties were identified and, as a consequence of that, our senior management team has been changed."
The NHS Midlands and East report says McFarlane had a 15-year history of mental illness and was under the care of the Suffolk Mental Health Partnership NHS Trust.
He was last assessed by mental health professionals just three days before the killing.
The investigation concluded that McFarlane's risk to himself had increased in the run up to the killing, but that he had no history of violence.
The decision not to detain him under the Mental Health Act was "a reasonable one" based on the information available at the time of the assessment, the report adds.
The report concludes: "The tragic murder was not predictable and although with the benefit of hindsight the admission to hospital... would most likely have prevented the offence at the time, this could not have been identified at any time by the various mental health professionals."
The inquiry started after the BBC revealed in May 2009 that shortly before the attack McFarlane was treated at West Suffolk Hospital.
Dr Ball said: "The investigation team have rightly identified some weaknesses in our care and treatment of John McFarlane.
"Although these did not cause what happened, they are clearly important.
"Although it is of little comfort to Mary Griffiths' loved ones, the report concludes that her tragic murder could not have been predicted."
Dragged from room
Sian Wicks, author of the mental health investigation, said several issues had been identified and lessons should be learned.
These include taking into account a person's profession when assessing the risk they pose and ensuring that all agencies communicate better with one another.
McFarlane, who worked as a slaughterman at the nearby Denham estate, took revenge after fitness instructor Mrs Griffiths posted a Facebook message saying he was "delusional" if he thought they would ever have a relationship.
He smashed through the back door of her home with an axe as she and her three daughters slept.
McFarlane dragged Mrs Griffiths from the room where she had been sleeping with her 10-year-old daughter and beat her.
She was shot twice in the chest and once in the left shoulder with a bolt gun normally used for stunning livestock.
In March 2011 the Independent Police Complaints Commission found that police should have been sent to Mrs Griffiths' home after she called them the night before she was killed.
But a report found Suffolk Police could not have predicted her murder. It said there were no misconduct issues.