A Cornwall mental health team has come under fire over its care of a patient who killed his wife.
An independent inquiry was set up after university lecturer Colin Obray stabbed his wife to death at their Cadgwith home in February 2002.
At the time, Obray, 63, was under the care of Cornwall Healthcare Trust, now Cornwall Partnership Trust.
An inquiry last year found the trust also made errors when dealing with another patient who killed his partner.
The latest inquiry, led by healthcare consultant Jane Mackay, considered the care and treatment of Obray.
Obray, who inflicted multiple knife wounds on his 60-year-old wife Ann at their bungalow on the Lizard, was given a hospital order by a judge at Exeter Crown Court in August 2002.
Obray pleaded guilty to manslaughter on the grounds of diminished responsibility.
The court heard Obray had threatened his wife in the bathroom at a previous house and had been receiving treatment in a mental hospital, but his wife wanted him home.
The homicide report, discussed by the South West Peninsula Strategic Health Authority (SWPSHA) board, named a number of shortcomings in his care.
The report, which refers to Obray as X, says: "There were shortcomings in the clinical management of X in terms of communication and systematic collation of symptoms. In addition hospital leave was poorly planned and inconsistently monitored."
The report also criticises the inadequate involvement of carers.
"More thought should have been given to the carers assessment of Mrs X. Additionally more could have been done to link into other family members."
The report also said sickness levels were high, resulting in the use of agency staff and called for improvements.
The report concluded that the death was not a direct result of any deficiencies in the care and treatment received by Obray.
The SWPSHA has developed an action plan which board members will be asked to endorse, but there are no recommendations for disciplinary action.
Tony Gardner, Chief Executive of Cornwall Partnership Trust, said: "It is worth stressing that many of the issues identified by the inquiry panel date back to procedures that were in place more than two years ago.
"Since then, significant improvements have been made to services and the way they are managed.
"Other changes and improvements, however, still need to be introduced and we shall be pursuing these with vigour."
Another independent panel last year found the Cornwall Partnership Trust made a catalogue of errors when dealing with Errol Leong, 38.
He admitted throttling his partner Tammy Little, 36, in Hayle Towans in November 2000.
The inquiry panel criticised the management style of the trust, supervision, training and communication.
The SWPSHA, agreed to make a number of urgent changes to prevent a similar incident, but no disciplinary action was taken.
In a separate case in 2000, Brian Trethewey, who was a manic depressive, stabbed his 51-year old wife Carol 16 times at Boscoppa, near St Austell.
A report said his care was reasonable, but did make four recommendations relating to better communication and the training of health professionals.