John Rous, 49, stabbed Jonathan Newby, 22, through the heart after he had drunk the equivalent of seven pints of beer and taken cannabis.
Mr Newby was alone in charge of eight mentally ill residents at the Cyrenians' Oxford hostel in October 1993 when he died. An inquiry by Oxfordshire health authority yesterday damned the Cyrenians, Oxfordshire social services, the health authority itself and the police for a catalogue of failures.
Fifty minutes before the killing, Rous rang 999 threatening to take out Mr Newby's liver and warning they were about to have "a dead corpse" on their hands. The police operator hung up and failed to alert the control room. "This one step alone would probably have averted the death of Jonathan Newby," the inquiry, chaired by Nicola Davies QC, concluded.
Its most fierce criticism was reserved for the health and social service authorities and the Cyrenians, who are accused of a "reprehensible decision" in leaving Mr Newby in charge alone. Their management committee "failed in the discharge of their duties". The health authority is accused of a "dearth of investment" in the 1980s, social services were notable by their "virtual absence", their relations with the Cyrenians were ones of "mistrust and suspicion", and the support John Rous received at Jacqui Porter House was "paper thin". He is presently in Broadmoor after being convicted of manslaughter.
An inspection of the hostel by the local authority failed to note that the rota provided for only one volunteer to be on duty at night - a breach of government guidance of which the inspectors, unless they were incompetent, must have been aware, the inquiry said.
Rous had been distressed in the run-up to the killing and "Jonathan Newby should never have been left in charge of such a home, still less at a time of considerable distress and actual danger," Ms Davies said.
The voluntary agency had, however, to take on the work "because of the dearth of any interest on the part of the statutory services", she added.
Mr Newby's death follows that of Jonathan Zito, stabbed to death on Finsbury Park tube station by Christopher Clunis, and other deaths, including that of Katy Sullivan in 1992 in a hostel run by Mind.
Mr Newby's mother, Jane, said the Cyrenians should be disbanded and the work taken over by statutory agencies. The Government's policy of community care was fatally flawed, she said. "It is not right to leave it to charities to fill the gaps."
John Bowis, the junior health minister, described the death as tragic and said he would examine how existing guidance should be strengthened. But he rejected suggestions that voluntary groups should not run such difficult services. "From this tragedy we should not get the impression the voluntary sector is not able to provide a service as good as a statutory body. We should distinguish between the use of the volunteer and the use of the voluntary sector."
Oxford Cyrenians accepted criticism that their growth had not been matched by the development of management and training. "We did over-reach ourselves to met a need that was not being met," Elizabeth Leyland, chairwoman of the charity, warned. She said it would need much stronger commitment from the statutory organisations if the inquiry recommendations on training and staffing and were to be achieved.
Damning indictment, page 3