Five days before Michael Stone bludgeoned Lin Russell and her daughter Megan to death in a country lane he told a psychiatric nurse that he wanted to kill people, according to a report out today.
Stone - who had a history of mental disorder, drug abuse and violence - had an "aggressive outburst" on 4 July 1996 and threatened to kill his previous probation officer and his family, the independent inquiry report chaired by Robert Francis QC found.
He also "made threats to kill prison officers should he receive a future sentence, saying he was too violent for prison and should be in Broadmoor".
The nurse's colleague, who was in an adjacent room, "was sufficiently concerned when he overheard the outburst to come into the room in case she needed assistance", it said.
During the meeting, Stone - who is now 45-years-old - told the nurse that the only way he could get off drugs would be if he was admitted to hospital.
The nurse told the Probation Service and a mental health social worker about the incident.
She also spoke to a mental nurse who told her that Stone had been offered a bed on many occasions, but had always declined.
He added that "in any event, staff at a local hospital did not feel they could cope with him on the detox ward".
On July 10 Stone attacked Dr Russell, 45, Megan, six, and her sister, Josie, then nine, as they walked home from a swimming gala in Chillenden, Kent.
Today's report commissioned by West Kent Health Authority - now the South East Coast Strategic Health Authority - Kent Social Services and Kent Probation Service found there were mistakes made in his care and treatment.
The report revealed that Stone's prison medical records were lost, meaning the full nature and extent of treatment he received there is unknown.
It stated: "It is of concern that the medical history of a man who has spent a substantial part of his life in prison is missing in this way.
"It is also of concern that the full details of his prison history were not made available to the authorities responsible for care after his release.
"There should have been a more systematic sharing of information from outside agencies."
The report said Stone was "one of the group of patients who are among the most difficult and challenging for the health, social and probation services to deal with".
It said: "He presented (us) with a combination of problems, a severe antisocial personality disorder, multiple drug and alcohol abuse, and occasionally psychotic symptoms consistent with adverse effects of drug misuse and/or aspects of his personality disorder."
It added that "this complex and shifting picture" of his mental health made it difficult for consistent and accurate diagnosis.
The report went on: "Even after a searching investigation by this inquiry, it is not possible to describe a full picture of the man, his history and his life, for much of it remains unknown.
"Each of the services dealing with him must have had an even less complete picture. His presentation to the many professionals who attended him during the period in question was for the most part compliant and apparently needing help; less often, he could be frighteningly aggressive."
The report went on to say that Stone received a "wide range of services" from all the agencies approached, and had regular and frequent contacts with professionals.
"This is emphatically not a case of a man with a dangerous personality disorder being generally ignored by agencies or left at large without supervision."Reuse content