In one of the most damning reports ever into a care in the community killing, an inquiry team listed a catalogue of failures both on a human and organisational level which led to a near-double tragedy.
Martin Mursell, cared for by Camden and Islington Health Authority and Islington social services, attempted to kill his mother Mary Collins and fatally stabbed his stepfather, Joe Collins, in a frenzied attack.
Mursell, 28, was jailed for life last year at the Old Bailey. He is now in Rampton hospital in Nottinghamshire.
The incident took place in October1994, eight months after Camden and Islington reported on Christopher Clunis, who killed Jonathan Zito. "It saddens me to say the lessons are not being learnt at all," said the chairman of the inquiry, Lincoln Crawford QC. "Since Clunis one would have expected by now people would be more diligent".
And despite internal inquiries by both health and social services no disciplinary action has yet been taken against any member of staff.
Mursell, a diagnosed paranoid schizophrenic with a history of violence had been hospitalised six times but on the last time his discharge was "woefully inadequate", the report said. He had referred himself to the Whittington Hospital, north London, but after two weeks was told to leave because the doctors said they could not see any psychotic symptoms.
While cared for in the community, housing, social services and health agencies "didn't seem to be talking to each other" said Mr Crawford. Mursell had difficulty getting accommodation, moving in between bed and breakfasts and his mother's home, and for long periods he did not even have an allocated social worker.
When he did have a social worker it was one who was not trained to deal with mental health. The inquiry was "struck by the inexperience" of staff and a supervisor said the case was "too much for [her] to handle".
Mursell's mother, Mrs Collins, repeatedly asked for help but her comments "fell on deaf ears" and she was left bearing the brunt of the responsibility. The inquiry concluded: "Despite Mrs Collins's cry for help when she telephoned the duty social worker, very little notice was given to her concerns."
"His treatment was very lacking," said Mr Crawford. "The failures were fundamental and depressing. It was in my view a failure by all the professionals involved with Martin Mursell. They let him down."
The chairwoman of Camden and Islington Health Authority, Sylvia Denman, said yesterday she had not ruled out the possibility of resigning but there had been a full-scale overhaul of care of the mentally ill over the last two years.
The social services staff who cared for Mursell had all left the borough as had most of the health team. No disciplinary action had been taken but both departments promised a review in the light of the report.
Mrs Collins said she was angry no one had been made responsible: "They say it's shortage of beds or underfunding which is true but I came across people who just didn't care ... I lost my husband and I lost my son. It is not enough to say that no one can be held responsible ... You can't make decisions and walk away from them and make people suffer."Reuse content