A REPORT into the care given to a widow who was killed by a man befriended in hospital criticises health and social services officials.
New procedures have been put in place since alcoholic drifter William Kilgallon battered Janet Frost weeks after they were both discharged from the North-East hospital.
But an independent inquiry panel which examined the case calls for further improvements to be made after it ruled the care Mrs Frost received was "less than optimal".
Panel chairman Ann Galbraith said: "We did identify shortcomings but even if all of those had been dealt with by the most effective best practices we can't say that this incident would not still have occurred."
Mrs Frost, 43, was killed in October 1999 at her home on the outskirts of Durham City, shortly after she became friends with Kilgallon when they were both inpatients at Durham County Hospital.
The mother-of-two was receiving treatment for depression following her husband's suicide a few months earlier, and the man was being treated for alcohol and prescription drug abuse.
Following their release in September, they continued to see one another and after Kilgallon was kicked out of his hostel, he stayed with Mrs Frost at her home in Meadowfield.
Kilgallon, who was 37 at the time, battered Mrs Frost around the head in a drunken rage and she choked on her own vomit. He was jailed for five years after pleading guilty to manslaughter.
The inquiry revealed Mrs Frost's daughters - one of whom was just 14 at the time, and her principal carer - had expressed concern about the relationship in the hospital and staff turning a blind eye to her drinking.
The panel's report, published yesterday, also showed there were shortcomings in how County Durham and Darlington Priority Services NHS Trust and Durham Social Services worked together on the case.
It says: "Opportunities were lost to share information . . . and to reassess risk.
"The panel has concluded that these problems were exacerbated by the lack of information which Patient Q's (Mrs Frost's) family had available to them about sources of help and support . . . and by the failure of many staff to listen to her family."
Peter Kemp, the county council's director of social services, said: "We believe our action plan is a full and appropriate response to the recommendations, and we accept that we shall be better at what we do because of it."
Harry Cronin, director of nursing at the Priority Services NHS Trust, added: "We are pleased to note that the inquiry panel acknowledges the significant changes and improvements that have been made to our services and systems since this incident occurred."
County Durham and Darlington Priority Services NHS Trust and Durham Social Services have drawn up an action plan following the case.
Some changes have already been made and others are due to be in place by next April.
Among the recommendations from the panel are a review of social services inter-teamworking, patient contracts at the hospital to outlaw alcohol and relationships between patients, improved contact with families and carers and better risk assessment.
Training needs of staff as well as record-keeping will also be improved.
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