The chair of an inquiry into the brutal murder of a man with learning disabilities has said she is 'hugely disappointed' by the NHS's failure to address the problems it identified.

Margaret Flynn chaired Cornwall county council's serious case review of the 2006 murder of Steven Hoskin by a gang who befriended him and moved into his St Austell flat. Dr Flynn found the NHS had "missed opportunities" to prevent the murder as both the victim and main perpetrator were well known to the NHS.

Dr Flynn said the gang leader was a "prolific user" of emergency, mental health and ambulance services. In an article for this week, Dr Flynn catalogued the 96 times he had come into contact with the NHS in the 17 months before the murder, including two admissions under the Mental Heath Act and 24 calls to the ambulance service, which had flagged him as "dangerous". At least eight of the calls were to the victim's flat.

Moreover, the victim's own use of NHS emergency and GP services had escalated for alcohol and physical abuse, yet no adult protection referral was made to the council's social services department.

In December last year Dr Flynn's review recommended that NHS South West commission an inquiry into Mr Hoskin's death to find out why information was not shared. In a statement, the strategic health authority said it was "still considering" the review's findings.

Dr Flynn said: "It is hugely disappointing that, four months after the review was published, the movers and shakers in NHS South West are insufficiently moved or shaken to have implemented the recommendations."

The SHA said it had asked for more information about the treatment of the killer, Darren Stewart, by mental health services in Cornwall and was planning a follow-up investigation. "There is a multi-agency action plan which is being monitored by the adult protection committee," it said.

The Department of Health is considering calls from the charity Mencap and Association of Adult Social Services to make its No Secrets guidance for cross-agency adult protection compulsory. A DH spokeswoman said it was vital future communication failings were prevented.

Cornwall and Isles of Scilly primary care trust director of community services Antek Lejk said: "More could have been done. We are ensuring that standard approaches are used for sharing information and identifying people in need of targeted support, particularly high-intensity users."

See Margaret Flynn's article on the Steven Hoskin case