The District’s mental health agency acknowledged Tuesday that it failed to properly monitor a discharged psychiatric patient with a homicidal history before he allegedly killed a neighbor in an unprovoked shooting in March. But the agency assumed no blame for the attack, asserting that “any attempt” to link its lax supervision to the victim’s death “would require undue speculation.”

In a public summary of a confidential report on its handling of the case of Hilman Jordan, the D.C. Department of Behavioral Health said that among a number of failings, its staff disobeyed a court order by not revoking Jordan’s freedom in the summer of 2018 after he tested positive for marijuana use four times in five weeks.

Jordan, now 46, who was acquitted by reason of insanity in an unprovoked fatal shooting in 1998, was held at the city’s St. Elizabeths Hospital for 17 years undergoing psychiatric treatment and was released in 2015. The D.C. Superior Court judge who approved his discharge ordered the behavioral health agency to immediately return Jordan to hospital confinement and notify the court if he was found to have used drugs.

Marijuana has long been a trigger for Jordan’s paranoia and schizophrenic delusions and a catalyst for violence, according to clinical reports filed in court.

Despite Jordan’s positive urine tests in 2018 — on June 28, July 13, July 19 and Aug. 3 — the agency allowed him to remain free and did not inform the judge, according to the summary. Also, the agency said, in the months before the killing, a community-based mental health provider, under contract with the city, failed to visit Jordan twice weekly and file reports on his psychiatric condition, as required by the court.

As for why the failed tests went unreported, “the Outpatient Forensic Review Board made a clinical decision to continue Mr. Jordan’s treatment in the least restrictive environment as the law requires with adjustments in his medication and increased monitoring,” the summary said.

“I have directed that over the next 120 days, the Department will conduct a wholesale review of . . . policies and standard operating procedures” for monitoring discharged insanity acquittees with violent backgrounds like Jordan’s, Behavioral Health’s director, Barbara J. Bazron, said in a statement. She said the review will involve a consultant with expertise in forensic psychiatry.

“The Department will take appropriate disciplinary action against employees responsible for identified failures,” she added.

On March 1 this year, seven months after Jordan’s last failed drug test, he allegedly shot and killed Javed Bhutto, 63, in the parking lot of the Southeast Washington condominium complex where they lived. Seven weeks earlier, Bhutto, who owned a condo with his wife directly above Jordan’s rental unit, had complained to Jordan’s landlord about the odor of marijuana persistently seeping into their residence from downstairs.

Jordan, charged with first-degree murder, is in the D.C. jail awaiting prosecution in Bhutto’s slaying. He has yet to enter a plea, and it remains to be seen whether he will raise an insanity defense as he did 20 years ago. In the earlier case, he fatally shot a longtime friend while in the throes of a psychotic delusion.

Bhutto’s wife, Nafisa Hoodbhoy, filed a wrongful-death lawsuit against the city in Superior Court last week, alleging that the D.C. government shares blame for the killing.

“The responsibility is squarely on their shoulders for failing to stop him,” Hoodbhoy said Tuesday night after being told about the agency’s findings. “I lost everything in my life because of the failure of the system, the failure of D.C.”

In its summary report, however, the behavioral health agency said that even if it had revoked Jordan’s freedom and notified the court after a failed drug test, a judge might have eventually released him again. Because Jordan’s insanity acquittal in 1999 meant that he was not legally culpable for that earlier killing, he was entitled to liberty if the court determined that he would not pose too great a threat to the public.

The agency also said that after the positive test Aug. 3, and before the homicide, Jordan submitted to regular urine screenings for seven months without a problem. As a result, the summary said, “the Department determined that any attempt to establish a causal nexus between the failure to return Mr. Jordan to the Hospital . . . and the March 1, 2019, shooting would require undue speculation.”

But Wayne Turnage, the District’s deputy mayor for health and human services, criticized that rationale in an interview Tuesday and raised doubts about the efficacy of Jordan’s urine tests in the months leading up the shooting.

Residents of the condo complex said Jordan would sit on his balcony for hours getting high. Videos posted on Jordan’s YouTube account in November 2018 show him with what appear to be marijuana joints. Bhutto complained about the odor of marijuana in January this year. And after the killing, a prosecutor said, Jordan tested positive for phencyclidine, or PCP, a powerful hallucinogen that is often mixed with marijuana.

“At the time, Behavioral Health was not requiring urine tests to be observed,” Turnage said. “He was allowed to produce his urine sample in private and hand it to the staff. When you don’t require a urine test to be observed, it increases the chance for mischief, that someone could use someone else’s urine. That has since changed.”

He said: “The key fact is, we made mistakes, and the mistakes were pretty egregious, and a resident of the city was horribly murdered.”

The summary was made public in advance of an oversight hearing set for Wednesday night at which members of the D.C. Council’s health committee plan to question Behavioral Health officials on a range of topics, including the Jordan case. The agency said the full report “contains information that is exempt from disclosure,” including confidential medical information and statements by agency employees “engaged in the process of critical self-evaluation.”

Behavioral Health officials said last spring that 129 insanity acquittees were under the agency’s supervision. Of those, 61 were St. Elizabeths inpatients and 68 were discharged patients living full time in the community under agency supervision, including 13 who, like Jordan, had been charged with murder or manslaughter.

“The outcome in this case was terribly tragic for the victim and his family,” the summary said. “It also represents the worse case scenario for the Department and its forensic clinicians.”