A Westcountry health board has admitted lessons must be learnt from the case of a man who killed his landlord while in its care, following recommendations made by an independent review.
Mike Bithrey from East Devon, died after he was stabbed in the neck Anthony Andrews outside his Bridgwater property in June 2012.
Mr Andrews, who was a dementia patient under the care of Somerset Partnership NHS Foundation Trust at the time, had made threats against his landlord but an investigation into the incident found this had not been fully disclosed to Mr Bithrey.
The review by health consultancy Verita also discovered that the Trust's community mental health team (CMHT) had not disclosed Mr Andrews' previous conviction for stabbing his wife to Mr Bithrey.
And it found that CMHT staff had not met with the Trust's safeguarding team to discuss whether Andrews should have been referred to Multi-Agency Public Protection Arrangements (Mappa) which deals with violent offenders.
The report concluded that the incident may have been prevented had Mr Bithrey been informed about Mr Andrews' previous conviction, his lack of remorse about stabbing his wife and his threats against him.
Lucy Watson from Somerset Clinical Commissioning Group, said she accepted that the "timely sharing of information regarding a potential threat to a person was the central lesson to be learnt from this review".
She also said she was "reassured" that the Trust was implementing the recommendations made in the report, but added:
"It can be challenging for health professionals to come to an accurate judgement regarding the potential risk of an individual harming themselves or others."
Andrews was detained at a secure psychiatric hospital following the incident and has since died.
