There was a sense of deja vu.

Despite warnings, despite a history of violence, despite previous court appearances, a mentally-ill patient had killed a man.

He was let down by the system, the independent inquiry found. Little comfort to the family of the victim who are still living through the nightmare.

It could be referring to one of many care in the community cases that have hit the national headlines in recent years.

But on Monday it was close to home. Schizophrenic Michael Donnelly, 32, of Avon Way, Greenstead, Colchester, had been failed by the system.

Michael Donnelly had refused to take his medication and in a crazed state set fire to his mother's house in Turner Road, Colchester in 1996, inadvertently killing Essex university student Matthew Bowyer, 22, the lodger who was asleep at the time.

Chillingly he had threatened to carry out the arson attack weeks earlier. This information had been passed to the authorities but was not shared between other agencies involved in Donnelly's care.

The details of his care had become "confused", the psychiatric service was reactive instead of pro-active and a "snapshot" of his mental Health was relied upon instead of an overview, the inquiry found.

Donnelly is now in maximum security Rampton Hospital for the crime, which he fails to understand the implications of because of his deteriorating mental health.

The independent inquiry into the treatment, commissioned by the North Essex Health Authority and Essex Probation Service, said lessons must be learned.

Lessons have had to be learned before. Out of a list of 48 recommendations the main theme was clear.

There must be better co-ordination among the services dealing with mentally ill offenders - the courts, the mental health teams, the police, social services and the health authority.

Information must be shared and all notes should be available for the relevant professionals making decisions about the patient.

In managerial terms it seems glaringly obvious. We must not be too scathing.

And despite calls by Dr Catherine Donnelly, the killer's mother, to urge the Press to find out which accountable medical professional is, in her view, primarily to blame for not listening to her warnings that Michael was mad and dangerous, we should not lose track by apportioning blame.

Since 1996, when the fire happened, a number of changes in care programmes for mentally ill offenders have already been put in place nationally, and of course in Essex.

And the current Government is still intent on tightening up legislation to ensure mentally disturbed offenders are dealt with appropriately.

But the report found there were a number of initiatives previously laid down by the Home Office and the Department of Health that had not been implemented at all in North Essex "to the extent that incidents such as these were more likely to occur".

We can retrain the court clerks, guide the caring professionals and co-ordinate every approach going, but if the wider picture dictated from the top is not as the Government said it should be, that is fundamentally wrong.

If procedure is sub-standard at the very heart, where the top dogs should be noticing it, then how are the professionals at the front line of care, having the daily contact with patients, to know policy is not in place.

It may be insensitive to say it. But in Donnelly doing what he did, in Matthew Bowyer's family being plagued with such grief, some good has materialised. The inquiry team has pinpointed large scale breakdowns in protocol in Essex.

Without it the wider picture may not have come to light. At least there is now hope that it will be fully addressed. The Donnelly file

Though Michael Donnelly had been diagnosed mentally ill in 1988, for seven years his care and treatment had gone smoothly.

Confusion only started in October 1995 after he was arrested for criminal damage on his mother's house.

In police custody he insisted he was a schizophrenic on medication. A forensic medical examiner found him fit to be detained and interviewed.

The following month Colchester magistrates adjourned the case and ordered a pre-sentence report.

Donnelly was bailed and during this time failed to turn up three times for appointments with his psychiatrist and for his medication.

In December he wrecked his flat slashing the settee with a knife and the GP was called in but could not receive an answer from him.

Three days later Donnelly's mother took him to the Lakes, the psychiatric unit in Colchester, and he received his injection.

But on a family trip to Ireland he bought a combat knife and threatened to use it and became aggressive. His mother informed the authorities who reported Donnelly was "fine, calm and settled" on January 2, 1996.

Further reports from Donnelly's mother followed about her son's disturbed behaviour, including his threat to burn the house down.

Donnelly appeared "stable" when seen by a mental health professional on February 8 but had indicated he wanted to decrease or stop his medication.

At the adjourned court hearing on January 10, 1996 there were a number of irregularities. Despite a request, a proper psychiatric report had not been prepared for the court, and instead the bench accepted a report prepared by the court diversion worker.

The probation service clearly said a probation order was inappropriate but one was passed, which included a clause ordering Donnelly to receive medication.

Such a sentence, it transpired, was illegal. Neither the court clerk, the bench, or Donnelly's legal representatives had realised this on the day. They could not attach a condition of medical treatment without evidence of a doctor.

Meanwhile Donnelly was refusing contact with Mental Health Services.

If Donnelly failed to turn up for his injection, a week should go by and then the probation service would be alerted.

It was also agreed he should receive further support from care staff.

The next day he turned up for this injection and again on February 5 His behaviour was not disturbed but for the second time, he had destroyed his box of injections.

He missed an appointment for his injection on February 23, 1996 and a note was made to let the probation service know if he had not turned up within the next week.

Before the end of the week Donnelly reappeared at court where the probation order condition relating to taking medication was removed.

The bench was told incorrectly that Donnelly was at the time taking his medication.

On March 1 the probation service was told, in accordance with the earlier agreement, that Donnelly's injection was a week overdue.

The message was noted but not picked up by the designated probation officer until March 4.

By this time the arson had taken place and Matthew Bowyer was dead.

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