Michael Folkes, 32, who had changed his name to Luke Warm Luke, stabbed Susan Crawford 70 times and beat her with a fire extinguisher. Despite a history of violence, he had been allowed to live alone and take responsibility for his own medication.
The killing happened eight hours after a doctor had put Luke on a list for emergency attention. He turned up in a distressed state at the Maudsley hospital on 3 October, 1994, but was allowed to leave. The following day Ms Crawford's body was found at his London flat.
Luke was convicted of manslaughter at the Old Bailey in 1995 and sent to Broadmoor.
The inquiry, which took four years and cost pounds 750,000, strongly criticised care of Luke, saying he should have been readmitted to a mental health unit because of the "signs of dangerousness" he was exhibiting. In 1993 he had carried out an attack of "striking similarity" on a depot guard.
Breakdowns between agencies and insufficient safeguards in his treatment and the administration of his drugs led to the tragedy, the inquiry said.
Luke's psychiatrist, Dr James McKeith, allowed him to stop being given injections of an anti-psychotic drug and take them in pill form, despite recurring aggressive episodes and failure to take his medication. The inquiry also criticised the fact that Luke was allowed to live in a flat by himself.
The report called for appropriate housing for mentally disordered people to be a priority and improvements to be made to support services for people in the community.
Lambeth, Southwark & Lewisham Health Authorityadmitted that "more could and should have been done to try to prevent this tragedy". Martin Roberts, the health authority's chief executive, said: "We want to make sure ... that everything that can be done is done to reduce the risk of such an event ever happening again."
Luke was first admitted tocare in 1986 and had a history of assault. He was described as "extremely dangerous".
Ms Crawford's daughter said it was "disgusting" that health chiefs had taken so long to apologise. Michelle Crawford, 22, was 17 when her mother was killed and looks after her sibling twins, aged 15, and her six-year-old brother, as well as her own three children. "It's taken four years for the inquiry to be completed. They should have apologised to my family way before."Reuse content