No disciplinary action has been taken against a Cornwall mental health team accused of mishandling a patient who strangled his partner.
An independent panel last year found the Cornwall Partnership Trust made a catalogue of errors when dealing with Errol Leong, 38.
He admitted throttling Tammy Little, 36, in Hayle Towans in November 2000.
He had been released from custody the day before, even though he threatened to turn Ms Little "black and blue".
The inquiry panel criticised the management style of the Trust, supervision, training and communication.
The parent body, the South West Peninsula Health Authority (SWPHA), agreed to make a number of urgent changes to prevent a similar incident.
These include a review of policies and procedures, improvements in training and qualifications and better integration between all mental health providers.
But it admitted no action had been taken against the team from the Cornwall Partnership Trust.
SWPHA Director of Partnerships, Anthony Farnsworth, told BBC Radio 4's File on Four: "The independent report showed a number of serious failings and we are not shying away from that."
He accepted that there had been a "gap in the continuity of care".
But no managers had been asked to resign, move to other jobs or faced disciplinary action.
Mr Farnsworth said: "The events themselves and the inquiry process and publication was a momentous event for the people concerned directly in the case and the people concerned with running that organisation.
"This is not a case of complacency. This has had a massive impact on people working in mental health services in Cornwall and on those of us who are responsible for ensuring that those lessons are learned."
Leong pleaded guilty to manslaughter in 2001 on the grounds of diminished responsibility and a judge at Exeter Crown Court ordered him to be detained indefinitely.