Weaknesses existed in the treatment of a schizophrenic who killed two friends, an independent inquiry has found.
Crone was diagnosed as schizophrenic
Sean Crone, 26, of Sunderland, stabbed 25-year-old Ian Lawson 24 times and slashed the throat of Simon Richardson, 27, in October 2003.
In January 2005 Crone, who was treated by South of Tyne and Wearside Mental Health Trust, was detained indefinitely after admitting manslaughter.
The inquiry said better communication and care arrangements were needed.
Days before the deaths, Crone was referred for help to the mental health trust and was awaiting an appointment for assessment.
But in the meantime, he killed his friend Mr Lawson in a frenzied attack, knifing him through the eye and brain.
He then went to see his best friend, Mr Richardson and slashed him to death with a razor.
During his trial it emerged Crone had symptoms of mental illness dating back to his teens and was a drug user.
He was diagnosed as a paranoid schizophrenic after being sent to Rampton Special Hospital in Nottinghamshire following his arrest.
The inquiry was ordered by Northumberland, Tyne and Wear Strategic Health Authority, which at the time monitored all local health trusts.
The inquiry, chaired by barrister Kester Armstrong, concluded that there was no direct link between the actions of the professionals involved in Crone's care and the deaths of Mr Lawson and Mr Richardson.
It concluded the deaths could not have been predicted or prevented.
But in 10 recommendations it urged more efficient exchange of clinical information between health agencies across Wearside.
It also called for "a clear strategy and procedures" for individuals who are reluctant to access and engage with services.
Steve Page, strategic head of patient safety for the North East Strategic Health Authority said: "The circumstances surrounding the deaths of Ian Lawson and Simon Richardson are deeply upsetting and our sincere sympathies are with the families of both men.
"The families have been very patient during the progress of the independent inquiry and we hope the final report goes some way towards answering questions they may have regarding the deaths of their loved ones."