A schizophrenic who killed a student in Colchester days after refusing treatment was failed by the system.

An independent inquiry into the care and treatment of patient Michael Donnelly has listed a catalogue of shortcomings.

And if the mistakes had not been made the tragedy may not have happened, it was acknowledged today.

Donnelly, 32, who had a history of mental illness and violence before the incident, set fire to his mother's house in Turner Road, killing lodger Matthew Bowyer, 22, an Essex University student, in March 1996.

The highly critical 121-page report, made public today at a packed news conference, laid the collective blame on agencies - including the courts, Health authority and probation service, which dealt with Donnelly.

And 48 recommendations have now been made to ensure a similar incident does not happen again.

But the arsonist's mother Dr Catherine Donnelly today laid the blame squarely on the shoulders of the local health authority, who she claimed refused to believe her son was a danger.

She said: "I had been desperately trying to get appropriate treatment for him for many years.

"The health authority failed more than the others. I was there all the time giving them the information."

Matthew's mother, Jennifer Bowyer, who cried as a statement from her was read out by another, said the report had not gone far enough.

She added: "It still does not explain why my son died, I thought I would get these answers but I haven't."

At the core of the problem was "disagreement" between the mental health service and the probation service on whether to deal with Donnelly as a sane criminal or a mentally ill person.

Donnelly admitted manslaughter of Matthew Bowyer and is currently held at Rampton maximum security hospital.

A statement on behalf of the NHS today admitted "weaknesses in the system let him down."

Nigel Beverley, chief executive of North Essex Health Authority, said: "It is extremely important we learn from what has happened and, with the benefit of hindsight, make improvements.

"I apologise to the two families affected by this case. I promise this report will be used to improve services."

Essex's chief probation officer Martin Wargent said: "There will always be more to learn and we will continue to work with the health authority and other agencies to find ways of keeping as many mentally ill offenders as possible away from the mainstream of criminal justice and providing them with appropriate medical assistance."

The independent inquiry was commissioned by North Essex Health Authority and Essex Probation Service.

Other organisations who helped with the probe included North East Essex Mental Health NHS Trust, Essex Police, Essex Magistrates' Court and Essex County Council Social Services.

Converted for the new archive on 19 November 2001. Some images and formatting may have been lost in the conversion.