A violent alcoholic stabbed his partner to death - on the same day a mental health team concluded he posed no risk to her.

A domestic homicide review has found “most agencies underestimated” the significance of concerns raised after David Creed, from Canterbury, “heard voices” telling him to kill Catherine Granger.

The mum-of-two had called 999 about the threats and an investigating police officer then submitted an ‘urgent’ mental health referral the following day.

This was not received by the Kent and Medway NHS and Social Care Partnership Trust (KMPT) until a week later.

Creed, who in the 1990s was convicted of stabbing someone in Margate, was then assessed as an ‘amber risk’ by mental health advisors, meaning he should be contacted within 72 hours.

But the review reveals it was not until five days later that attempts were made to call the 53-year-old.

After being unable to get hold of Creed, ‘Single Point of Access’ (SPoA) advisors referred the matter to the Community Mental Health Team, which concluded he posed no risk.

It discharged the case - but that same day Creed knifed Ms Granger, 50, multiple times at the flat they shared in Long Acre Close.

Creed, who was suffering from alcohol dependency syndrome, was charged with murder following the stabbing on December 29, 2020.

But he was convicted of the lesser charge of manslaughter by diminished responsibility after his plea was accepted by the prosecution.

Creed was jailed for 16 years at Maidstone Crown Court in August 2022.

Following the case, a domestic homicide review was commissioned by the Kent Community Safety Partnership, which is made up of agencies including the police and local authorities.

Its report, published in September, concluded the assessment process “did not recognise” the potential risk Creed posed, and the urgent police referral should have been graded by KMPT as ‘red’, which requires immediate intervention or contact.

“The level of violence used by [Creed] against [Ms Granger] up to the point of [her] murder did not indicate an escalation in terms of the severity of injury,” the report states.

“But it was significant the voices [he] was hearing did say he should kill [her].

“It is this change in what the voices were telling [him] to do that most agencies underestimated the significance of in terms of future risk.”

In a heartbreaking statement given as part of the review, Ms Granger’s mum, Christine Ash, described how the tragedy has left the family devastated.

“Nothing will ever bring her back and life must go on for all my dear family,” she said.

“Our complete jigsaw is now and always will be missing one vital piece.

“My sorrow as her mother, her sister’s loss and the loss of a mother to her children cannot be replicated.”

Ms Granger began a relationship with Creed in 2013, and both struggled with alcoholism.

Police were called to multiple incidents of domestic abuse at the home they shared before a “relatively rapid deterioration of the relationship” in the months before her death.

The report says in the months leading up to the stabbing, Creed told authorities a number of times about hearing voices - telling him to self-harm or attack Ms Granger, but not to kill her.

He failed to attend appointments with his GP and mental health teams - and in October was advised to self-refer to the Forward Trust, a charity supporting people battling addiction.

On December 14, Creed was arrested and taken into custody after Ms Granger called 999 to say he “had gone into one” about not having the TV remote.

Police attended and Ms Granger disclosed that Creed had said “the voices” in his head were telling him to kill her.

In response to a plea from Ms Granger for help, the officer obtained Creed’s permission to submit an ‘urgent’ mental health referral, which was done the following day and which KMPT received a week later.

The report says: “Five days later, the SPoA made two attempts to contact [Creed] by telephone. This was in breach of the 72-hour deadline.

“Unable to make contact, the matter was referred to the local Community Mental Health Team (CMHT) to make an urgent follow-up with [Creed].

“The CMHT reviewed the referral made by SPoA the next day and concluded [Creed] posed no risk and discharged the case.

“It was recommended [Creed] was referred to Adult Social Care and should make a self-referral to Forward Trust.

“[Creed] was arrested for the murder of [Ms Granger] the same day.”

Creed left his partner with eight wounds to her front and back, including one that pierced her aorta and proved fatal.

The report says it is not known if officers ever disclosed Creed’s previous conviction history to Ms Granger, which could have been a consideration under Clare’s Law - a police policy giving people the right to know if their current or ex-partner has any previous history of violence or abuse.

NHS Kent and Medway’s chief nurse Paul Lumsdon, speaking also on behalf of KMPT, offered his “sincerest condolences” to Ms Granger’s family.

“We are committed to continually improving the support we offer people who are affected by domestic abuse and recognise there were areas for all involved in her care to learn from,” he said.

“We treated the recommendations made by the review with the utmost seriousness and, together, have made the necessary changes and also implemented additional improvements.”

Kent Police’s Det Ch Supt Emma Banks says domestic homicide reviews are “incredibly important” as they “give us the opportunity to reflect”.

“As a learning organisation, we welcome opportunities to improve and develop our service,” she said.

“The recommendations from the review have been implemented with a new referral process for vulnerable adults being applied and a training package for all frontline staff to ensure vulnerabilities are identified and cases are prioritised efficiently.

“Our thoughts and sympathies continue to be with those who are still grieving her loss.”

A Kent County Council spokesperson says the basis of the review is a “human tragedy” and the authority’s thoughts remain with the victim’s family.

“We have taken the recommendations of this report, as we do with any, extremely seriously, and have been working together with our partners to ensure that they are met,” they said.