The mental health chief in charge of Glaister Earl Butler's care was today instigating an investigation into what was "in the minds" of health workers who met Butler in the weeks leading up to the killing.
Sue Turner, chief executive of Birmingham and Solihull Mental Health Trust, announced an internal and an external inquiry into the events surrounding the fatal actions of Glaister Earl Butler.
In a statement by Birmingham and Solihull Mental Health Trust Ms Turner said now the trial was over, the internal inquiry would be resumed to see what lessons could be learned.
?In addition... there will be an independent inquiry by the Birmingham and The Black Country Strategic Health Authority which investigates the circumstances and makes recommendations from its findings,? she said.
Birmingham Crown Court heard Butler had been detained under the Mental Health Act on three occasions ? in 1994, 1999 and 2001 ? after displaying similarly aggressive, hostile and paranoid behaviour as on the day Det Con Swindells was killed.
Throughout his enforced stays in hospital and care in the community, there was concern he was not taking his anti-psychotic drugs.
Butler maintained he was not ill and would take his medication intermittently.
A spokesman for Birmingham and Solihull Mental Health Trust said he had appeared to clinicians to have been taking his medication and was not showing any signs of relapse.
On April 27, less than a month before the killing, mental health workers visited Butler for a review. They saw a knife sticking out of a sofa and knife marks in the hallway. His explanation ? he was practising martial arts. Satisfied with that explanation, the workers did not notify police.
On Saturday, May 15, staff visited him to drop off medication, only for him to tell them he had received it a week before. At a team meeting on Monday, May 17, concerns were raised and a key worker and two students called round to his house later that day.
?The questions for me are, why wasn?t he taking his medication and what the impact on his mental state and well-being was, and what could have been done differently to avoid a tragedy happening like this again?? said Ms Turner.
?These are very serious questions and I am impatient to start the review again. Then we will take action.?
Marjorie Wallace, the chief executive of mental health organisation Sane, said: ?The greatest known predictors of tragedies like that of the killing of Det Con Swindells are living alone, failing to take medication, a history of aggression and delusions about people in authority and neighbours. It?s a fatal combination,? she said.
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