Kevin Keegan stabbed his wife Janet in a London street in August 1997.

At the time he was already on bail for abducting his son-in-law and granddaughter at knifepoint.

Mrs Keegan was being housed at a supposedly secret location after fleeing years of abuse and threats to kill by her husband.

Despite police fears that Keegan might harm himself or others, the CPS decided in June not to oppose bail at a hearing in June 1997 and he was allowed out.

The independent inquiry, chaired by barrister Alison Gulliver, said the CPS decision not to oppose bail was "the one matter which would have made a significant difference to the outcome of events".

However, the inquiry also criticised long delays in Keegan's treatment and inadequate training of staff at the care in the community hospital where he was placed.

Care plans for Keegan were "confusing" and more support should have been given to Mrs Keegan, the inquiry said.

It made 20 recommendations for changes in services, policies and procedures at Haringey Social Services and Healthcare Trust.

History of psychiatric problems

Keegan had a long history of psychiatric problems, domestic violence and a criminal record dating back to childhood.

His daughter was just six when she was placed on the child protection register in 1980 and the report said Keegan beat his wife, son and daughter "over a long period".

Mrs Keegan was forced to beg and steal food from shops while her husband spent money on drink and drugs.

She repeatedly left him between 1990 and 1997, but returned time and again after he attempted suicide.

In 1990 doctors diagnosed Keegan as suffering from a severe anti-social personalty disorder.

Keegan repeatedly refused psychiatric treatment, missed appointments and did not take medication aimed at controlling his problems.

Just three months before the murder, Mrs Keegan again left her husband and was placed in emergency bed-and-breakfast accommodation.

Keegan was placed in the newly-opened Alexandra Road Crisis Centre in Haringey.

Crucial conversation

The Crown Prosecution Service was blamed by the report

The next week he told a residential social worker at the hostel that he wanted to kill his wife.

However, the social worker did not report the conversation to police because he thought it was "the effects of drink".

When the shift leader at the hostel reported the matter to the service manager for Haringey Mental Health Services, the manager did not take the threats to kill seriously, the report found.

Training of staff at the hostel to assess the risk patients posed was limited to just three hours and focused on suicide rather than violence towards others, the inquiry said.

The report said: "The staff who had to deal with Mr Keegan did not appear to have received adequate training to manage the situations which arose."

Long delays in Keegan receiving psychiatric treatment and "confusion" over who was responsible for ensuring he took medication also led to problems.

Huge pressures

In 1996 there was a four-month delay between Keegan seeing a GP and being admitted to St Ann's Hospital in Haringey.

Huge pressures on senior consultants meant Keegan was seen by a succession of junior doctors.

The report said: "Further consideration needs to be given to the conflict between training needs and the need of patients for continuity of care."

The inquiry also found that communication between staff responsible for housing Mrs Keegan and social services staff looking after her husband was non-existent.

On August 11 Mrs Keegan moved into a one-bedroom flat in Haringey, the location of which was supposedly kept secret from husband.

However, Keegan found out from a friend where his wife was living and on August 16 confronted her in the street outside her flat and stabbed her.

Marjorie Wallace, chief executive of the mental health charity SANE, said: "This is a shocking killing.

"We would like to see new laws for people with severe anti-social personality disorder who did not fit into either the health services nor the prison system, and units supervised by staff trained in risk assessment."