JAMES Fortey, 44, was stabbed to death yards away from his family home on Caerleon Road on August 4, 2007, by his friend Kevin Price.

On December 20, 2007 the court ordered Price’s indefinite detention in a secure hospital.

A review of the mental heath care for Price prior to the murder revealed a series of failures allowing Price to slip through the net, causing the chief executive of the local health board to apologise to both families yesterday.

No individual was blamed in the review by the Healthcare Inspectorate Wales (HIW) but it found although Mr Fortey’s death could not have been predicted, better care and treatment could have averted the likeliness of Price committing murder.

The Commission found a number of failings by the mental health services, while his symptoms showed a significant warning of increased risk, there was no indication of Fortey having a violent nature prior to the murder.

Price was allowed to miss appointments with the Community Mental Health Team and the Commission criticised the fact he was then often discharged without staff following up failed appointments.

Price even said on one occasion he was wasting the community psychiatric nurse’s time and they should no longer visit.

The report said staff were not supported by senior consultants and the post of team leader had not been properly developed leading to undermining by other staff.

Price was allowed to get away with not always taking prescribed antidepressants and anti-psychotic medication.

Mandy Collins, deputy chief executive of the HIW, said keeping appointments is very difficult for people with mental health problems and they often do not want to accept they have a mental illness.

She said it is therefore important to keep a consistent update with these individuals.

The review found Price was not diagnosed with schizophrenia until after being charged with Mr Fortey’s murder and he was only admitted to hospital once in 2003 after taking a drugs overdose.

The report criticised the lack of support to Price’s parents with whom he was living with at the time of the murder.

Price first entered the mental health services aged four when his parents were concerned by some of his behaviour.

But psychiatrists at the time considered him to be a “normal little boy.”

Price found secondary school work difficult which led to truancy and him leaving school at 16.

He held a number of unskilled manual jobs, including taxi driving, which is when Mr Fortey’s family said the two friends met.

The review said Price could form relationships, having male friends and relationships with women, including one lasting four years.

But Price became delusional and reported an incident to the police about Mr Fortey in 2002, then becoming fearful his friend would know it was him and retaliate.

He believed Mr Fortey and his ex-landlord made videos of him to post on the internet, said he saw cameras in lampposts outside his parents’ house and thought people in the street were laughing and talking about him.

He became increasingly isolated, staying in his room with his curtains closed.

In the weeks before the murder, he began going to the supermarket and visiting his sister’s house as he did on the day of the murder.

He first saw the specialist mental health services as an adult in July 2002 after being referred by his GP with depression.

His last appointment with a psychiatrist was on March 28, 2007, before she went on maternity leave.

The report said responsibility for Price was not formally transferred or reallocated to another psychiatrist.

The local health board said the review’s recommendations have already started to be put in place, including spending an extra £750,000 on creating an assertive outreach service to offer more immediate follow-ups.

The team closely monitors whether people are taking their medication and when they are not, they are seen by a doctor.

Chief executive of the Aneurin Bevan Health Board said mental health remains a key priority and the Care Programme Approach has been improved over the last two years, with families and carers more involved.

Ms Collins said she was confident the Commission’s recommendations will work but said no-one can guarantee it will not happen again.