THE mother of a Borth man who killed a dog walker in a random attack is demanding a public apology from a health board for both her son and the family of the man he killed.

David Fleet, 20, stabbed 71-year-old Lewis Stone just days after being discharged from a psychiatric unit.

He was sent home despite warnings about his worsening mental state.

Ten days later he stabbed Mr Stone, a retired butcher from Stafforshire, on a footpath on the banks of the Leri near Borth Wild Animal Kingdom on 28 February 2019.

Mr Stone died as a result of his injuries three months later.

BBC Wales Investigates - in a documentary that airs on Monday night - has discovered that an unpublished health board review into David Fleet’s care, prior to the attack, reveals how three weeks before he was sent home, a doctor warned he wasn’t ready to be discharged because of his worsening mental state and the risk he posed with knives.

The Cambrian News reported at the time that Fleet was deemed "safe" by authorities."

But days after the review, he was sent home to be cared for in the community without anyone updating his risk assessment.

His mother, Sharon Lees, says she had also warned staff of her concerns and the fact that during home visits he was still looking for knives and had started using cannabis again.

She said: “It has resulted in two families being devastated. Ultimately this could, should have been prevented. There were enough warnings there.”

The findings of the review were not publicly shared – including with the victim’s family.

But a copy, seen by BBC Wales Investigates, also reveals that the day before the stabbing, mental health staff were meant to contact David Fleet but didn’t.

He’d been due another dose of his anti-psychotic medication but didn’t receive it.

His mother says that Hywel Dda University Health Board told her in a private letter that changes had been made to its mental health services following the killing. But for her and her son that is not enough.

She tells the programme: “It’s really important for not only us, but the Stone family to have a public apology….because of his illness and the lack of care he received it only feels justified that he also receives an apology because the health board failed him which in turn then failed his victim’s family.”

The health board told the BBC it couldn’t publish the findings of the review because it contained confidential medical information, but that it did share them with some of its own staff and the Welsh Government.

The Welsh Government has the power to commission independent mental health homicide reviews into such cases but BBC Wales Investigates discovered it has not done so since 2016. That means the lessons identified in David Fleet’s case and three others were not shared directly with other health boards.

That has been criticised by leading barrister and peer Lord Alex Carlisle.

He said: “We learn from previous disasters how to avoid future disasters. Why don’t they want to do these reviews? I don’t understand it, unless it’s on the basis that they can be costly. Well that’s not a proper basis for not carrying out reviews, not commissioning reviews. Doing nothing for seven years, I mean it’s a seven-year scandal.”

The Welsh Government said it was satisfied independent reviews had not been necessary for the last seven years because individual health boards had thoroughly investigated their own cases. But in a statement, it admitted the review system needed to change to ensure better “communication and co-ordination” and said a new one is being introduced to make it easier for all agencies to access lessons and learn.

David Fleet admitted manslaughter on the grounds of diminished responsibility.

Diagnosed with paranoid schizophrenia, he was sentenced to be detained indefinitely at a secure mental health unit.

His victim’s family have described him as a “monster” and say that for them, there is no excuse or forgiveness for what he did. They say they want him to remain locked up and that life without Lewis – a loving husband, father, and grandfather - is agony.

The Cambrian News reported last year how the family of Mr Stone, were left heartbroken after being told by police that Fleet was being allowed unescorted leave - less than four years after the fatal stabbing.

Burton MP Kate Kniverton said she had written to the Ministry of Justice on the issue.

Sharon Lees believes more information about what led up to the attack should have been shared with the Stone family and more widely.

She said: “If other health boards across the whole of the UK were made aware of the failings in this case, then it would have an impact on perhaps the care of people in other health boards. And it would prevent tragic cases like this from ever happening again."

BBC Wales Investigates: How Did Our Sons Become Killers? is on BBC One Wales and BBC iPlayer 8.30pm Monday, 5 June