UPDATE: Murder of 22-year-old Cerys Yemm in Argoed 'could not have been predicted or prevented' by health services, report finds

The Healthcare Inspectorate Wales published its report today which looked into the murder of 22-year-old Cerys Yemm from Oakdale and the mental health history of her killer Matthew Williams, 34.

Police were called to the Sirhowy Arms Hotel, in Argoed’s High Street, at 1.23am on November 6, 2014 to reports of a man attacking a woman.

On arrival, they found Williams, an ex-offender attacking Miss Yemm, who was from Oakdale. He was tasered by a police officer and was later pronounced dead.

A separate investigation by the Independent Police Complaints Commission has yet to publish its findings.

The inquest opened into the death of Miss Yemm which was held in November 2014 heard the provisional findings showed she had died as a result of "sharp force trauma to the face and neck".

The HIW report found that from his adolescence Williams was a 'prolific drugs user' and had started using cannabis at 11 to 12-years-old, which they say had a negative impact on his mental health.

Williams used a variety of illegal drugs at various points in his life including heroin, amphetamines, ecstasy, mephedrone and LSD.

He was diagnosed with Schizophrenia in 2004 but this was never re-evaluated and the HIW team said it is unclear given his illicit drug use whether this diagnosis can be fully relied upon.

The report states that in the immediate days leading to November 6, 2014, he was in a 'low mood, pessimistic about his future' but 'without signs or symptoms of mental illness such as psychotic symptoms.'

The HIW team who reviewed the evidence concluded the change in his behaviour at the Sirhowy Arms Hotel where he killed Ms Yemm is likely to have been as a result of a severe reaction to taking illicit and/or psychoactive substances.

Drug-induced psychotic disorders occur during or after substance use and symptoms can be very similar to schizophrenia.

The reports states schizophrenia should not be diagnosed during states of drug intoxication or withdrawal. The review team felt that a sufficient drug free period didn't occur when Williams was diagnosed in 2004.

The report states Williams did not display typical schizophrenic symptoms between 2004 and November 2014.

The HIW's review team believe it is likely Williams required long term psychiatric care and treatment as he was 'vulnerable' outside prison due to continued drug misuse, possible personality disorder and 'chaotic lifestyle.'

They said his use of illicit substances in a 'binge fashion' was highly likely to continue and would have resulted in further psychotic episodes.

He was prescribed medication for the illness until July 2014 but this was stopped as there was an absence of reported psychotic symptoms.

Williams had a total of 26 convictions against 78 offences. He spent time for 41 offences in juvenile custody and 14 offences in adult prison.

Offences included assault occasioning actual bodily harm, wounding with intent, three relating to assaults upon police officers, three weapons related offences, 14 drug related offences and 15 offences committed while on bail.

He received his first custodial sentence at 15-years-old for two years. The last two years of his life was spent in HMP Cardiff and Parc Prisons.

He was serving a custodial sentence for blackmail when he was released on licence in September 2013. He was subsequently arrested 11 days later after breaching licence conditions and was returned to Cardiff prison where he served his whole 27 month sentence.

He was released from prison on October 23, 2014 without any statutory supervision and spent 14 days in the community before killing Miss Yemm.

On his release from prison he was described as 'functioning well.' Williams initially tried to find accommodation in Newport to be closer to his father but couldn't prove he had a close enough link to the area.

The report says there was 'pressure' on Caerphilly council to find accommodation for Williams as he was homeless. The council had been using the hotel since 2008 as emergency bed and breakfast accommodation.

On his arrival to the hotel he was turned away by the owner as she believed he was 'drunk and stoned.' She turned him away until he returned in an 'acceptable presentation' and was allowed in.

Wallich Homeless Charity are commissioned by Caerphilly council to provide help and advice to homeless and vulnerable in the area. A senior support worker attempted to contact him a number of times after an initial visit but without success.

The report states that Williams missed two appointments with the social worker.

The report says the HIW team were 'concerned' to learn of the absence of risk information such as individual's prior offence which should have been shared by Caerphilly council with the owners of Sirhowy Arms Hotel.

Sirhowy Arms Hotel owner Mandy Miles has previously told the Argus she had no knowledge of Williams’ previous conviction of violently assaulting his ex-partner.

She has been trying to sell the hotel since Miss Yemm's death and agrees with the Yemm family that it should be demolished. The family of Miss Yemm launched a petition last year to have to site demolished as they said it was a ‘constant reminder’ to the family and the local community of the event.

The report states that no significant 'root causes or factors' have been identified which led to the 'unfortunate and tragic' event of Miss Yemm's murder.

Williams visited his GP on October 29, eight days before he killed Miss Yemm, to obtain a sick note. The GP at South Street Surgery gave him a four week sick note based on his previous diagnosis of schizophrenia and said he had no concerns regarding Williams.

Williams told the GP he had made an appointment the following week with a community mental health nurse and psychiatrist but no appointment had ever been made.

Sirhowy Arms owner Mandy Miles

Kate Chamberlain, chief executive of HIW said yesterday that the GP had no cause for concern as Williams showed 'no signs of immediate risk to others'. She said at that time he was a 'free man' and chose not to engage with services provided.

She said: "Mr Williams was reluctant to engage with the support available to him and this had tragic consequences. However, our review has concluded that it would have been difficult for health services to have predicted or prevented what happened.

"The incident of 6 November 2014 touched everyone connected with it. Our review makes a number of recommendations, including recommendations on support for families and staff following such events. Whilst none of these reflect issues considered to have materially contributed to the incident it is important that we use this opportunity to learn and improve services for the future."

The report states the first contact with mental health services was in April 1997 after Williams was arrested and charged with theft of a motorcycle and attempted burglary. He was admitted informally to Ty Sirhowy Acute Mental Health Unit. He was discharged two and a half hours later after he was found using cannabis. Five days later he was informally admitted again at the request of his mother following a fight with his brother.

He was discharged a day later after Williams said he had no intention of giving up cannabis and amphetamines.

His third admission was in May 2004 after concerns were raised by Williams and his partner as 'he didn't feel real, he had green creatures crawling out of his hands.'

He was on a number of different anti-psychotic medication while staying at Ty Sirhowy Mental Health Inpatient Unit.

In June 2004 he was detained under section two of the mental health act after presenting 'psychotic like symptoms.' The report states that Williams' conversations appeared 'bizarre, talking about dead babies in his nose'.

He was discharged in July after five weeks at the mental health unit. From June 2011 to October 2014 he received care from mental health services during his time in prison.

The report makes 10 recommendations in respect of the care and treatment provided to Williams but said they do not believe that the 'presence of these issues contributed to this tragic incident.'

These include that Caerphilly County Borough Council should ensure that a summary of risk is shared with manager of the community accommodation where the individual is being housed.

It also recommended the council take steps to ensure regular communication with managers of community accommodation and should provide training to staff relating to illicit substances and safeguarding issues.

A spokesman for Caerphilly County Borough Council said they accepted the findings of the report.

Cllr David Poole, CCBC Cabinet Member for Housing, said: “First and foremost I would like to take this opportunity to express our deepest sympathy to the family of Miss Yemm. We are keen to learn from the outcomes of the review so that appropriate steps can be taken to reduce the chance of anything like this ever happening again in the future.”

The report recommend that HMP Cardiff, Aneurin Bevan Health Board, HMP Parc and Cardiff and Vale University Health Board should develop a process where case formulation is routinely introduced and updates as a prisoner moves from prison to prison and mental health care services.

The report also recommends that Welsh Government review the provisions and the availability of more structured interventions for individuals within the community who have mental health issues or substance misuse.

The report says there should be better sharing of healthcare information prior to discharge from prison and after care planning to local community mental health care teams. It was also recommended that support should be provided to families affected by such incidents.

A statement from Dean Yemm, Ms Yemm's father said: "We as a family welcome that the independent investigation and report carried out by the HIW has finally come to conclusion.

"The only victim in this case was Cerys. A fact that we feel has been lost."

The family of Williams said they did not agree with the contents of the report in its entirety. They said they had concerns over the lack of information provided to HIW and have identified inaccuracies in the report.