The BBC's Richard Hannaford on the inquiry

The inquiry team, chaired by Patricia Scotland QC, said the 1994 killing of 33-year-old Susan Milner by Michael Folkes bore " a striking similarity" to an attack he committed the year before.

Michael Folkes was sent to Broadmoor indefinitely

It says that if Mr Folkes, who changed his name to Luke Warm Luke by deed poll, had been admitted to hospital before both attacks they could have been prevented.

The inquiry team also makes wider recommendations about mental health provision, calling on health authorities and trusts to ensure mental health doctors' caseload is not too heavy and recommending the provision of out of hours crisis teams.

Community care

Michael Folkes was suffering from paranoid schizophrenia and had been released into the community when he stabbed Susan Milner 70 times at his London flat in April 1994.

Folkes, 32, was an outpatient under the care of the Bethlem and Maudsley NHS trust, having been released from hospital against Home Office and expert advice by a Mental Health Review Tribunal.

His release was on the condition that he continued to take his medicine.

However, he later refused to take injected anti-psychotic drugs and asked to be allowed to administer his own orally taken medicine.

His aftercare team and the Home Office were not told of the decision, despite him having become violent on numerous previous occasions when he stopped taking injected medication.

Tests after the attack on Ms Milner demonstrated no traces of medication in his body, showing he had stopped taking his medicine.

Susan Milner was stabbed to death with scissors

The day before he attacked the mother of four, he had gone to the Maudsley Hospital in south London in a distressed state.

He was put on an emergency list for a community nurse to visit him.

Mr Folkes, who reverted to his original name in 1994 and was described by one psychiatrist as "an extremely dangerous man", had been in and out of mental institutions since 1983.

He had taken the name of Luke Warm Luke from a character in the BBC1 comedy series Porridge in 1992.

He was convicted of manslaughter in 1995 and was sentenced to be detained indefinitely at Broadmoor.

Lack of communication

The inquiry team criticised the lack of communication between the community care team dealing with his case.

The three members of the aftercare team did not meet once together in the 25 months leading up to the killing of Susan Milner.

The inquiry also criticised the decision to allow Mr Folkes not to take injected medicine. It said: "It would be difficult to identify a more important decision" since medication had kept him relatively stable.

Folkes was released from hospital a year before killing his friend

It also slated the health authority for failing to discharge Mr Folkes into a staffed hostel.

It said that, had he not been forced to look after himself, the killing would not have happened.

Its wider recommendations on mental health policy include a call for appropriate sheltered housing for mentally disordered people and the provision of community forensic outreach teams of specially trained nurses and psychiatrists.

The government has backed the provision of crisis mental health teams in its review of mental health care, but has not yet stated how much money it will provide for any changes in policy.

An announcement is expected in the next two weeks.

Lambeth, Southwark and Lewisham health authority and the Bethlem and Maudsley NHS Trust welcomed the report and said they recognised that more should have been done to prevent the killing.

But they said they had made many changes since 1994.

They are considering whether disciplinary action is necessary.

The health authority added that it would draw the report, which recommeds changes in mental health legislation, to the attention of the Mental Health Act Commission and the Department of Health.

There have been 22 inquiries into attacks by community care patients in the last year.

Mental health law

Mental health charity Sane, one of the organisations which helped with the report, said 96% were due to lack of communication and in one in three cases the patient had asked for help.

Marjorie Wallace on a system in crisis

Chief executive Marjorie Wallace said the whole system was in crisis. "It is so fragile it cannot contain one human error," she stated.

Saying that community care could work and stressing that only a minority of schizophrenics were violent, she called for changes in mental health legislation.

Marjorie Wallace: 'It's not that Michael Folkes slipped through the net. It was not tight enough.'

Ms Wallace said that to introduce a "safe, sound and supportive mental health system", the government would have to rewrite mental health law.

"We need to balance the rights between the patients, and the families and the public, and that's what we hope that this new legislation will do."

The government will be bringing out its own report on reforming mental health care in the UK next spring.

However, mental health charity Mind said the inquiry report showed no need for an extension of existing powers since Mr Folkes was released on condition he take his medication.