Independent investigators highlighted a series of police failings today that preceded the brutal murder of a 15-year-old girl by her violent and obsessive ex-boyfriend.
Arsema Dawit, 15, was stabbed to death near her home in flats near Waterloo station, south London, after ending her relationship with 22-year-old student Thomas Nugusse on June 2, 2008.
Five weeks before the killing, Arsema went to a police station with her mother, Tsehaynesh Medhane, to report that Nugusse had attacked and threatened her. She asked for him to be arrested.
The Independent Police Complaints Commission (IPCC) found "collective and organisational" failings in the Metropolitan Police response to her complaint, which was slow and incomplete.
And officials warned that an "almost unmanageable" burden of work for some senior officers in an already understaffed unit creates a risk that other cases may fall through the net.
Rachel Cerfontyne, of the IPCC, said a civilian station receptionist and detective constable "could have done more", but were not responsible for what happened to Arsema.
She said: "Tragically through omission, misunderstanding and assumption, the messages and information given by the family on the night of April 30 were not sufficiently acted upon.
"I was concerned by the high workload of the inspectors interviewed as part of our investigation, in particular the almost unmanageable volume of work some supervisors are responsible for and the risk it creates of cases falling through the net."
Nugusse was committed to a mental hospital indefinitely after an Old Bailey jury found he had killed Arsema in May last year. He suffered brain damage after making two attempts to hang himself in prison.
Speaking after the verdict, Mrs Medhane said her world has been changed for ever and her daughter's life could have been saved if police had taken action at the first opportunity.
On April 30, 2008, Arsema went to Kennington police station to report that Nugusse, whom she had had a two year relationship with after meeting through a Camberwell church, had attacked and threatened her.
Independent investigators examined the actions of an inspector, a detective inspector, a detective constable and a station receptionist who handled her allegations.
They found the receptionist failed to inform a senior officer there had been a death threat, to record contact details for Arsema's cousin or to seize mobile phones as evidence.
The detective constable did not conduct a timely and effective investigation as a result of leave, other commitments and the fact he relied on a school officer to contact the victim.
Both received advice from managers as a result of their shortcomings. No fault was found with the inspector or detective inspector.
But officials did highlight how the detective inspector was carrying a double workload as he managed 60 officers in a CID office, crime office, missing persons unit and financial investigations unit while a second inspector was on leave.
The IPCC found Arsema's complaint was one of six cases with "particular concerns" out of 48 crimes the inspector was asked to look through when he arrived at work one morning.
Responding to the findings today, Met Commissioner Sir Paul Stephenson said he understood the "grief and anger" of the victim's family.
He said: "We will study the IPCC report. I do note there are some organisational issues, but I also note the IPCC have been clear they did not contribute to the tragedy."
Commander Simon Bray welcomed the report and said the force has addressed seven of eight recommendations made by the IPCC.
He said: "We expect the highest level of professionalism from all of our staff and accept the failings in this case."Reuse content