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A psychotic man has beheaded his pal in a Paddy Power betting shop after he was released from a mental health ward.
Hassan Mustafa, armed with four separate knives, is said to have tracked down Khalid Yousef, 28, to the betting shop in Handsworth, Birmingham.
It was there that the 28-year-old was butchered by Mustafa, with the gruesome murder taking place in front of terrified staff and customers in January 2018.
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Only now has a coroner's office deemed the release a "very serious failure", as Mustafa should have been referred for treatment prior to the murder, coroner James Bennett has said.
A nurse assessing Mustafa's mental health following an arrest made on the man under suspicion of burglary less than a month before the tragedy is said to have missed the fact that Mustafa was psychotic.
Coroner Bennet said the nurse had failed to recognise he was "floridly psychotic", even though Mustafa said that the Queen was responsible for a so-called "league of extraordinary gentlemen".
It was that belief that Mustafa had "followed clues" of that led him to the site where he was arrested.
A detective constable involved in the case also said they did not want Mustafa released.
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The coroner has blamed the nurse's inexperience, inadequate training and supervision, as well as the absence of psychiatrists, as reasons for the decision to allow Mustafa to walk free.
Mustafa came into contact with police a total of three times in the month before he killed Yousef, with the first encounter finding Mustafa in possession of nun chucks and a wheel brace.
Mr Bennett's report, reported by BirminghamLive, read: "Khalid was killed by another person who was severely mentally ill and acted upon his delusional beliefs.
"The significance of the perpetrator's presentation on December 13 was not appreciated and it meant he was not referred to mental health services when he should have been.
"Had he been referred he would have received treatment and/or been detained and the death would not have occurred."
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