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Danny Shaw
Home affairs correspondent, BBC News
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Richard Whelan was stabbed through the heart
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This report has a familiar, if depressing, ring to it.
There was no particular event - no one mistake or single oversight - which led directly to the killing of Richard Whelan by Anthony Joseph.
There was no one individual - or one agency - who made an error so bad that the report's authors could say "it was their fault" that Joseph was at large when he should have been in custody.
Instead, the report found that Joseph's mistaken release on 29 July 2005 was due to a series of administrative problems and slip-ups over a period of about four months.
Take one of the mistakes in isolation, and it is not that serious.
False address
Put them together and the result is that a persistent, and sometimes serious, offender is at liberty when he should be in prison.
To those behind the review, the mistakes highlight "attitudes and cultures" of the criminal justice system to dealing with cases of people who commit offences while on bail.
One example is that Joseph - who had nine convictions to his name between 2001 and 2005 - supplied a false address when he was bailed by magistrates in London in March 2005.
But the non-existent address was never checked by police.
Anthony Joseph admitted manslaughter
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On another occasion, a police custody officer in Surrey "knowingly" entered incorrect bail information into their computer system.
The information was not updated when it should have been, and that, said the report, "may have had some bearing on subsequent events".
The impression from reading the report is that the agencies in the criminal justice system - police, prosecution, courts, prisons - were just not fleet-footed enough to keep up with the likes of Anthony Joseph.
Joseph had at least seven aliases; he offended across England; and his crimes were carried out while he was on bail for other offences, committed in other parts of the country.
To deal with people like Joseph promptly and effectively requires staff to follow the correct procedures; and it requires a computer system which can be widely accessed by everyone who needs the information.
In that respect, the report echoes failings identified by the Bichard inquiry into the way the Soham murderer Ian Huntley evaded police checks: wrong information in the system; details not shared between agencies.
There are also parallels with two more recent cases, that of police inspector Gary Weddell who killed while on bail for murder; and Garry Newlove, who was murdered by a gang, one of whom was on bail.
The Ministry of Justice is investigating whether the bail laws need tightening - and the case of Anthony Joseph is almost certain to feature in its review.
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