The family of a man killed in an axe attack by his cousin believe he would still be alive if his killer had received the correct treatment.
Ryan Lowry died after his mentally ill cousin Ashley Rowen chased him down the street and struck him 13 times with the blade in Partington.
Mr Lowry's family said they have seen a report from the mental health trust that cared for Rowen highlighting 'many problems' in his previous care and treatment.
They say the beloved 36-year-old died 'so unnecessarily' and would not have been killed had mental health teams given his cousin the proper treatment.
Greater Manchester Mental Health NHS Foundation Trust confirmed they have undertaken an extensive internal review following the horrific attack.
They have come up with a 'comprehensive action plan' to prevent similar incidents in the future.
A court heard Rowen, from Trafford, suffered from paranoid schizophrenia.
Mr Lowry, a foster parent and racing fan, had taken on the role of Rowen's carer, Minshull Street Crown Court heard.
But Rowen had stopped taking his medication before the fatal attack in February 2020.
The tree surgeon had been twice sectioned under the Mental Health Act before he committed the fatal attack.
He had spent around two weeks at Moorside Psychiatric Unit in Trafford after leaving his grandfather with a bleed on the brain in 2019.
A judge described his quick release after just a couple of weeks as 'surprising'.
The day before the fatal attack on his cousin, Mr Lowry attended a doctor's appointment with his cousin, where Rowen said he had not been taking his medication as it made him sleepy and he had put on weight.
He was prescribed further medication and he was given contact numbers for the mental health team should his symptoms worsen.
That night he vandalised his ex-father-in-law's home.
On the day of the fatal attack, a community mental health team called Rowen after being contacted by Mr Lowry, who had told them Rowen was presenting with signs of a relapse, the court heard.
When Rowen answered, he assured them he was fine. He went on to kill his cousin just hours later.
Greater Manchester Mental Health NHS Foundation Trust identified key areas of improvement in Rowen's care.
They included risk assessment management and the handover of care between teams.
The 32-year-old pleaded guilty to manslaughter on account of diminished responsibility.
He was sentenced to an indefinite hospital order on Monday, January 4.
Judge Maurice Greene said that 'had he not been ill' he would not have killed his cousin.
In a statement after the hearing, Mr Lowry's family said a hospital order was the 'only appropriate custodial sentence'.
But, they said: "We all still struggle to understand why Ryan, who was such a beautiful and caring man, lost his life so unnecessarily, and in the way he did.
"We have seen a report from the Mental Health trust that highlights many problems in the previous care and treatment of Ashley Rowen - including managing the known risks he posed to others.
"It seems that only now - after this horrific murder- will he be getting the effective care essential to ensure he will not commit serious harm to anyone again.
"We only wish he could have received that treatment beforehand. Because if he had, we believe Ryan would still be with us, and so much grief, suffering and trauma could have been avoided."
The family added that they hope in future they would see 'real evidence' that lessons have been learned.
They added: "We hope...Ryan’s untimely death will lead to effective change, so that no other family has to experience what we have been through ever again."
The family also paid tribute to Mr Lowry, describing him as a 'kind, loyal, talented, hard-working, and generous young man'.
They said: "He left his mark on everyone that knew him. He was just a lovely bloke.
"He is sorely missed - not only by his close and immediate family, but also by his many friends from school, work, and in the racing and fostering communities.
"His death deeply affected hundreds of people, and continues to do so."
What the trust has to say
A spokesman for the trust said incorporating the recommendations from the review into Rowen's care will remain a 'top priority'.
Gill Green, director of nursing and governance at Greater Manchester Mental Health NHS Foundation Trust (GMMH) said: “Our deepest sympathies go to Ryan’s friends, family and all those who cared for him at this sad time.
“As an organisation, we are committed to continuous learning and improvement.
"We have carried out an extensive internal review, and are now in the process of incorporating recommendations from the review into a comprehensive action plan to prevent similar incidents in the future. These actions will remain a top priority for the Trust.
“However, we understand that this comes too late for Ryan, and our thoughts remain with everyone who was affected by this tragedy.”
The trust said the review looked fully into the circumstances and events leading up to the incident.
The aim of the review was to understand what happened, why it happened and identify where lessons can be learned in order to prevent similar type incidents occurring in the future.
Key areas for improvement included; the handover of care between teams/individuals, pressures on the capacity of teams/individuals, risk assessment management and formulation and contact with external agencies.
