An independent review has criticised a mental health trust's treatment of a man who was repeatedly in contact with its services but went on to kill one neighbour and injure another.
Leicestershire Partnership trust said it was already several months into a comprehensive review of models of care and may move to a more integrated service which would improve links with other services.
The report, written last summer but only released after a Freedom of Information Act request, makes a series of recommendations after assessing the care of Scott Walker, who had a history of drink, drug and mental health problems.
Mr Walker had made various threats against other people and was recognised by those dealing with him as "a risk to public safety", the report states.
He was first referred to the trust's community forensic service after completing a prison sentence in 2005. He was turned down for assessment on the basis of the referral letter and no firm arrangements for his care were made. Six months later he was assessed by the crisis resolution and home treatment team after he was arrested.
He indicated he would go to a specialist personality disorder service, where he had failed to attend appointments before, and no other input was offered.
He appears to have had no contract with the mental health service from April to September 2006, when he stabbed his neighbours, killing Debra Larn. He was later jailed for life.
The review is critical of the way in which the trust dealt with requests from other agencies and says that if they had been better handled it might have influenced later events.
"The trust did not work effectively with partner agencies to manage the public risk," it says. "The community forensic service failed in its duty to consider this case appropriately." It adds that the crisis resolution home treatment assessment was carried out by staff with insufficient expertise and that parts of the assessment form were incomplete.
HSJ's Transforming Forensic Mental Health Services conference is on 24 June, www.hsj-forensicmentalhealth.co.uk