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25 September 2014, 17:27 | Updated: 30 March 2016, 13:50
A series of hit and runs in Cardiff - which killed a mum and injured 20 others - couldn't have been predicted or prevented, according to a new report.
Health Inspectorate Wales says van driver Matthew Tvrdon should have been given proper mental health support.
The report says the 32 year old was sectioned 4 times between 2003 and 2007 and wasn't supervised when he was released.
He also stopped taking his anti psychotic medication around a year before the hit and run's happened.
Alan Jones is the Head of Investigations at Health Inspectorate Wales. He said: "The safety net wasn't in place for Matthew following his discharge from mental health professionals.
"That safety net would have been on-going monitoring that he was taking his medication, physical health checks and general contact with services."
The focus is now on what lessons can be learned.
The watchdog says mental health patients should be properly monitored and have a care plan.
Prescriptions should also be monitored to make sure medication is being taken,
In a statement - Cardiff and Vale University health board says it's acting on the reports recommendations and has carried out a review of services to make sure they are appropriate and safe.
After a trial at Cardiff Crown Court - Matthew Tvrdon was detained indefinately under the mental health act.