There were “missed opportunities” to assess the mental health of a woman with schizophrenia who killed an 88-year-old man and injured three other people in a supermarket, an inquest has found.

Zara Radcliffe killed John Rees in the attack at a Co-op in Penygraig, Rhondda Cynon Taf, on 5 May 2020.

Coroner Graeme Hughes recorded a narrative verdict, and said Mr Rees was “unlawfully killed” by Radcliffe, who was 30 when detained under a hospital order for the attack five months later.

He found the way the community mental health team – made up of Rhondda Cynon Taf social workers and medical staff from Cwm Taf Morgannwg health board – monitored Radcliffe after she was released from hospital was “insufficient”.

He found a planned phone call with Radcliffe on 30 April did not happen and that, if it had, it was “more likely than not” that Radcliffe’s care co-ordinator would have become aware she not been staying at home or taking her medication.

He added that their failure to complete an updated risk assessment when she was in the community probably further contributed to Mr Rees’s death and was another “missed opportunity”.

Recording a narrative verdict at the court in Pontypridd, the coroner found that Mr Rees was “unlawfully killed” and that the “assailant was suffering from psychosis and symptoms were not being managed”.

The four-day inquest heard that Radcliffe’s father Wayne had raised concerns about her on the day of the attack.

He made multiple phone calls to the crisis mental health team, telling them she had started taking recreational drugs again.

He said his daughter had become “withdrawn and agitated”. No one called him back, but a care coordinator did make plans to visit the home later that day.

At about 14:00 BST, Radcliffe made her way to the supermarket and used wine bottles and a fire extinguisher to attack her four victims.

She later told police: “I knew I would kill someone today.”

Radcliffe was then sent to Rampton high security hospital and, in October 2020, detained indefinitely.

The inquest was told Radcliffe had previously assaulted a police officer and medical staff.

Some of the team who treated her during a four-month inpatient stay at the Royal Glamorgan Hospital gave evidence, outlining a diagnosis of schizophrenia with symptoms including aggression and volatility and hearing voices which she believed would harm her.

The court heard that, after two weeks of consistently taking an antipsychotic drug, they believed she was improving and that at discharge on 24 February 2020, was considered a low risk.

Her care was handed over to the community mental health team but she had only two interactions with them in the next ten weeks, in part due to Covid restrictions.

Paul Mears, chief executive of Cwm Taf Morgannwg UHB, said the health board had learned from the case, establishing an adult mental health inpatient improvement board “to ensure we continually focus on the delivery of high quality, safe and effective care to the service users and carers in contact with our mental health inpatient services”.

He added that a recent review of inpatient mental health services at the Royal Glamorgan “acknowledged the significant improvements”.