Doreen Griggs was killed in 2004 (Photo: Courtesy of Wisbech Standard)
A report into the care of a 19-year-old mental health patient who killed his grandmother in her home says the death could not have been prevented.
Jay Wilson, 19, was detained under the Mental Health Act after killing Doreen Griggs, 68, at their home in Wisbech, Cambridgeshire, in December 2004.
The report, issued by NHS East of England, makes 18 recommendations to improve mental health services.
Wilson had received community care from health services in Cambs and Norfolk.
Dr Paul Cosford, regional director of public health, said: "On behalf of NHS East of England, I would like to express my sincerest sympathies to all concerned in this tragedy.
"Improvements to the care and treatment of people like Jay Wilson have been identified in the independent report, and we welcome the recommendations.
The house where Doreen Griggs lived (Photo: Courtesy of Wisbech Standard)
"The independent report's recommendations provide specific actions to build on the improvements already carried out by the Foundation Trusts."
At the time of the killing, Wilson was under the care of the community services of the former Cambridgeshire and Peterborough Mental Health Partnership NHS Trust.
He had also been under the care of the former West Norfolk Primary Care Trust, who provided inpatient mental health services in King's Lynn.
The report published today examined the care and treatment of Wilson from when he first received treatment from the mental health services to the time of killing.
Key recommendations from the independent report included improving record keeping and documentation, the systems for supervision and the allocation of staff.
The independent panel found that the fatal attack, by Mr Wilson, on his grandmother could not have been predicted or prevented.
Dr Cosford said it was "regrettable" the length of time it had taken for the report to be completed.