THE random street killing of a Caerphilly pensioner by a 23- year-old man could have been avoided, a report concludes.

But failings by health and social care services in Gwent, Caerphilly and beyond contributed to “many shortcomings” in Martin Davies’ care over a number of years and, in the months leading up to Gwen Poole’s death there were “a series of missed opportunities to provide better and more structured care for him.”

Davies stabbed Gwen Poole, 66, four times with a bread knife as the mother-of-two waited for a lift in Llanbradach in March 2009. She was on her way to play skittles.

Arrested shortly afterward, Davies was detained indefinitely in a high security hospital last summer, after admitting her manslaughter on the grounds of diminished responsibility.

Healthcare Inspectorate Wales (HIW) said it had “serious concerns” about Davies’ case, and the report into its background, published yesterday, lays bare his troubled mental history and various efforts to diagnose and manage his condition.

His behaviour had first caused concern in primary school, and he had a long and complicated history of contact with social services and mental health teams in Gwent.

He had spent time in Ty Sirhowy, a mental health unit, and in a hospital in Scotland, before a period of detention under the Mental Health Act in a private facility in the West Country, where he was referred by the former Gwent Healthcare Trust.

The HIW report found his discharge from that detention, in October 2008, was not managed properly and there was evidence Davies was likely to harm himself or others in a crisis.

Aneurin Bevan Health Board, which has replaced Gwent Healthcare Trust, and Caerphilly council has introduced a number of new individual and joint working arrangements to try to address some of the shortcomings highlighted in the report, which itself includes more than 20 recommendations.

In a joint statement, the health board and the council offered “a sincere and unreserved apology to all those involved”, accepting the identified failings within both organisations.

It said: “We have already taken action to prevent the circumstances, which led to this tragic event occurring again.”

Mental healthcare provider Cygnet also acknowledged the report’s findings and issued an apology.

EDITORIAL COMMENT: Lessons must be learned

THE case of a schizophrenic who killed a woman in the street is made all the more appalling by the revelation it was a death that could have been prevented.

Martin Davies stabbed Gwen Poole, 66, with a bread knife as she waited for a lift in Caerphilly in 2009.

Yesterday the Health Inspectorate Wales said it had “serious concerns” about the case.

A report found there was a “great deal of evidence” that Davies was likely to harm himself or others in a crisis.

It also found “many shortcomings” in his care over a number of years and “failings” by various health and social care organisations and care providers.

And in the two months before the killing, the report identified opportunities that were missed to admit him to hospital either as an informal patient or under the Mental Health Act.

Davies was detained indefinitely in a high-security hospital after he admitted her manslaughter on the grounds of diminished responsibility.

Yesterday NHS Wales apologised for the failings and the chief medical officer for Wales said incidents like it were isolated.

That may be the case, but even one death that could have been prevented is too many.

We hope lessons are learned from this before another avoidable death occurs.