One of the women residents had been causing disturbances, upsetting the others who lived at the home to the point where staff had discussed whether they would have to have her committed to a secure unit.
No action was taken and John Rous, who resented that the attention of the staff was being focused away from him, sought solace with friends at a bed-and-breakfast hostel where he had a few drinks, smoked cannabis and may have taken other drugs.
Rous, who had been diagnosed a schizophrenic at the age of 16 and lived rough on the streets of Oxford for many years before becoming a resident at the home, also had a grievance about money which he believed he had loaned to the Cyrenians, the charity which ran the establishment.
On that Saturday evening Jonathan, who graduated in film studies from Leicester Polytechnic the year before and had been a volunteer since April, began his 24-hour shift at 5pm, a couple of hours before Rous rolled in from the pub.
In his drunken state, Rous hammered on the door of the office where Jonathan had locked himself, demanding cash which was eventually handed over to him.
Rous returned to the pub where he sat drinking and brooding, returning to the home again shortly after 8pm. This time, in an effort to keep him away from other residents, Jonathan decided to take him into the office.
Within minutes Rous had stabbed him twice in the chest. Jonathan staggered out into the street to seek help, but collapsed on the pavement and died shortly after.
Two days after his death Jonathan's mother, Jane Newby, 48, was told by Thames Valley Police that a civilian switchboard operator, Brian Coombs, had taken a 999 call at 7.32pm from Rous on the night of the tragedy saying that he had a knife and was going to kill someone.
The operator ignored the call with the result that the police, who could have been at the home within minutes, were not on hand when Rous returned from the pub. Mr Coombs, who was singled out for particular criticism by the inquiry team, lost his job but was reinstated on appeal, though he has now left of his own accord.
Rous, who was 47 at the time of the killing, pleaded guilty to manslaughter on 17 June last year at Oxford Crown Court and was ordered to be detained at Her Majesty's pleasure. He is currently being held at Broadmoor secure hospital.
Yesterday, dramatically holding the shredded T-shirt that Jonathan was wearing on the night he was killed, Mrs Newby said of her son: "He may not have grown up to be a prime minister or a film star, but he would have grown up to be a decent human being. He never got that chance."
She said the Government had to take responsibility for her son's death. "A lot of people let down our son - but I suppose at the end of the day it's the Government's policy of community care. I think it is very flawed."
Hospital closure programmes should be halted until proper resources were placed into caring for mentally-ill people in the community.
If the Government wanted to do it properly, ministers would have to accept this more humane approach to care would be more expensive, she said.
It was not right that it was left to charities to fill in the gaps in care. Statutory services paid for by the taxpayer should take on that role, she added.
Mrs Newby concluded by lifting up Jonathan's shirt. "That didn't happen. What happened was this. I've washed out the bloodstains."Reuse content