A paranoid schizophrenic who killed a man and hurt five others after hearing voices ordering him to murder English people was repeatedly failed by the NHS, an investigation has found.

An independent inquiry into the treatment of Ismail Dogan found that he “slipped through the safety net” of mental health care services in North London.

The authors claim Barnet, Enfield and Haringey Mental Health Trust and the Haringey Teaching Primary Care Trust failed to share information about treatment, engage with his “isolated” family and assess his care in the community.

Two days before Christmas in 2004, Dogan left his family home with a knife and after driving around Tottenham and Edmonton attacked six strangers within 90 minutes. He stabbed one man to death and hurt four men and a woman.

The minicab driver, originally from Turkey, later told police that he had heard a bird telling him he was the son of Allah and so should kill English people.

Dogan, now 34, was convicted of killing Ernest Meads, 58, and is currently being held at Broadmoor top security hospital.

He had been diagnosed as a paranoid schizophrenic three years before the killing and placed in the care of the community mental health care team after being released from a psychiatric ward.

The investigation has again renewed calls for a review of the way mentally unstable people are being cared for in the community.

Marjorie Wallace, chief executive of Sane, said the findings highlighted a series of “blunders” that showed how the NHS was failing patients and putting innocent people at risk.

Last week Surrey and Borders Partnership NHS Foundation Trust was criticised for its poor treatment of Daniel Gonzales, a paranoid schizophrenic who murdered four people, despite his and his family’s repeated appeals for help.

Referring to the latest report, Mrs Wallace said: “Yet again the warnings and pleas of family members went unheeded, with fatal consequences.

“Following so soon after the Daniel Gonzales report, it begs the question: is care in the community working? Can all patients be safely treated by a jigsaw of mental health teams which fail to communicate with each other, respond to crises, or assess and act upon the risk that some individuals may pose to themselves or others?”

The charity is calling for a "red alert" system where police and mental health are called on to respond immediately to family’s warning that a relative poses a threat.

The inquiry found Dogan’s care was severely compromised by the lack of consistent medical management: “For this the consultant medical team must take a great deal of responsibility.”

The authors said that it was obvious Dogan was a “significant risk”, particularly after he had been repeatedly held in police custody for acts of violence.

The report adds that Dogan’s risk assessments were not always coherent or complete, meaning that when his mental health reached crisis point there was nothing in place to try to identify or rectify the problem.

“It is the view of the investigation team that there was a significant system failure in that a disjointed tripartite system was operating whereby inpatient services, outpatient services and community mental health teams operated separately,” the report says.

“At the time that Dogan was receiving his care different Consultants led the inpatient and outpatient services thereby ensuring that there was little continuity of care. This was compounded by poor communication systems and a care coordinator who appeared to have been performing to a standard well below that expected from someone of her experience and seniority.”

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