A report into the circumstances surrounding the killing of a
retired accountant by a mental health patient has highlighted
failures by health and social services in Cardiff.
Paul Khan was convicted last year of manslaughter with diminished
responsibility for the killing of Brian Dodd in March 2003 in
Prestatyn, north Wales.
At the time, Khan, who was diagnosed with paranoid schizophrenia
and had a history of drug misuse, was under the care of the Cardiff
community forensic psychiatric team. He had been assessed the day
before the killing. The report, commissioned by Cardiff Local
Health Board, said the “12-hour missing rule” had not been enforced
by Cardiff’s community mental health team. Khan should have been
reported to the police because he had been missing from his Cardiff
flat for more than 12 hours. But the team told Khan’s parents to
contact the police themselves and only registered him missing three
The report recommends tightening arrangements for discharging
patients into the community and a greater use of 24-hour supervised
hostels across Wales. It calls for local health boards and the
Health Commission Wales to monitor progress on these proposals.
The report also highlights the failure of clinicians to set
“specific and measurable” indicators for the community team to
assess whether Khan was in danger of unpredictable behaviour. It
calls on the NHS trusts involved in his care to examine these.
Marjorie Wallace, chief executive of mental health charity Sane,
said the safeguards to protect Khan from himself and others were
ignored. “It is shocking that when he went missing, those in charge
of his care took no action, leaving his parents to sound the
The Welsh assembly has ordered the Health Commission to audit
discharges from medium secure units and for the Healthcare
Inspectorate to inspect clinical governance. It will give a formal
response to the report early next year.