The death of a teenager stabbed on her way to school could have been prevented if her killer had been given mental health treatment, a report has found.
Christina Edkins, 16, was killed by Phillip Simelane, 23, on a bus in Birmingham in March 2013.
An inquiry found that medical staff, police and the prison service missed chances to get him treatment he needed.
Simelane, from Walsall, had been diagnosed with paranoid schizophrenia. He admitted manslaughter last October.
He was detained indefinitely under the Mental Health Act by a judge at Birmingham Crown Court.
A review into Christina's death was commissioned by Birmingham Cross City Clinical Commissioning Group, on behalf of all agencies that had dealt with him.
The chair of the review panel, Dr Alison Reed, said: "The attack on Christina was random and unprovoked and therefore it could not have been predicted.
'Matter of time'"However, it is the conclusion of the panel that as Christina's death was directly related to P's mental illness, it could have been prevented if his mental health needs had been identified and met."
The report found that Simelane's mental health problems were first identified 11 years ago, when he was at school.
It said despite repeated requests by his mother to GPs and social workers to get him treatment, they ignored her.
He was involved in several violent incidents including assaulting a police officer and threatening his mother with a knife, for which he was sent to prison in July 2012.
'Meaningless and avoidable'Simelane spent more than 100 days in HMP Hewell, where he was diagnosed as psychotic and given medication for his condition.
He was released with only three days worth of medication and no long-term drugs plan, the report said.
After being sent back to prison for drugs offences he ended up sleeping rough on the streets of Birmingham in December 2012.
Philip SimelaneApril 2007 : Reprimanded by police at the age of 16 after being found in possession of a lock knife
March 2009 : Given a police caution after pushing his younger brother into a wall
May 2012 : Arrested for criminal damage after breaking into his mother's house and throwing an electric fire at her
May 2012 : Holds a knife to his mother's stomach after accusing her of trying to kill him
July 2012: Is jailed for 101 days after being convicted of assault and battery in the attack against his mother
October 2012 : Seven days after being released from prison, he is convicted of trying to steal a car and possession of cocaine and breach of licence. Spends 59 days inside HMP Birmingham.
December 2012 : Released from Birmingham Prison and lives rough on the city's streets.
March 2013: He fatally stabs Christina Edkins on the bus in Hagley Road.
Source: Birmingham Cross City Clinical Commissioning Group report
The report made 51 recommendations calling for the improved sharing of mental health information between agencies including the NHS, the police and the prison service.
In a statement, Christina's family said they agreed with the findings of the report that the attack could have been prevented.
"It was predictable that, without treatment, Phillip Simelane, would eventually resort to a knife attack on another person and it was only a matter of time before he carried out his threats to kill."
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Simelane was on the bus for more than two-and-a-half hours
The family said they hoped many recommendations in Dr Reed's report would be implemented so that "no other family has to experience the heartache of such a meaningless and avoidable death of a loved one".
Simelane's family said in a statement: "Our son was discriminated against by the system that was put in place to protect him.
"The mother's cry was not heard or taken into consideration until innocent lives were impacted upon.
"Having read the heart-touching report, we wonder if it will change anything in the future or is it just a paper exercise meant to put our hearts at peace for little while?"
Birmingham CrossCity CCG said it had already implemented a number of recommendations which included improved access to mental health patients' records and better use of assessments that were done in prison.
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