Michael Horner, 52, was discharged from an acute psychiatric ward at Queen's Park Hospital, Blackburn, in March 1996. The following day he telephoned the hospital to say he had killed his wife. By the time police got to the house he had hanged himself and his wife Hazel had been strangled.
The independent inquiry published yesterday found that his care had fallen below acceptable standards, his illness was not taken seriously and he was not correctly diagnosed. Mr Horner, who was suffering from a paranoid personality disorder and depression, was left without a primary nurse for the last 12 days of his month-long stay, and his discharge was seen as a "misjudgement" the report into Blackburn Hyndburn and Ribble Valley health care trust said.
Mr Horner was sent home without his wife being informed by hospital staff. She was planning to leave her husband and was packing when he returned to their home in Lower Darwin, Lancashire.
We consider that the discharge of Mr Horner to home while his wife was still there packing with a view to move out within three days was most unfortunate and probably contributed to her death," the report states.
It also said that a full-risk assessment of Mr Horner should have been made before his discharge because he had attempted and threatened suicide while an in-patient.
There was also concern about a lack of communication between staff and the report highlighted a general "laissez-faire" attitude, which led to poor standards in patient care. It also showed a lack of close personal involvement with consultant psychiatrist Dr David Franks and stated that as a patient Mr Horner had been inadequately observed.
The day after his release, when Mr Horner rang the hospital ward to say he had killed his wife, the report also shows there was some delay before staff rang police. When officers finally arrived at the house they found the two bodies.
Lisa Rawlinson, 31, one of the Horners' two daughters said yesterday that if her mother had realised her husband was coming home she would have moved out.
"My mum has died unnecessarily," she said. "Her death could have been prevented by one telephone call to tell her he was coming out.
"To have lost one parent is horrifying enough but to lose two is devastating."
Marjorie Wallace, the chief executive of the mental health charity Sane, said: "It is chilling to read the inquiry's own conclusions that Michael Horner's suicide was `predictable and regarded as almost inevitable'.
"Nevertheless he was discharged home by staff who knew his wife was planning to leave him. No one consulted his wife or family in this critical decision - as so often happens."Reuse content