Damning list of failings; Report reveals missed chances which may have saved two lives.

Byline: Warren Manger

FIONA Stephenson and Colette Lynch were stabbed to death by the very men who promised to love and protect them.

Their partners both had a history of violence which was known to social workers and mental health services in Warwickshire.

But a series of "unreasonable" failings left the men free to kill, a damning independent inquiry has found.

Fiona Stephenson was brutally killed in her own bed by her husband Owen in Hillmorton, Rugby, in January 2005.

Just four weeks later Colette Lynch was knifed by her ex-boyfriend Percy Wright outside her home in nearby Overslade.

Both killers were cleared of murder but convicted of manslaughter and Wright has already been freed.

Yesterday health chiefs in Warwickshire received a fresh report on the killings - just three weeks before a new inquest into the death of Colette Lynch is due to start.

The report included a damning list of failings flagged up by the inquiry and the progress made on an action plan to tackle those shortcomings.

Colette's mother Helen Lynch - who was also stabbed by Wright - spoke to the Telegraph after he was released in April this year.

She said: "Nobody listened to Colette in 2005 and nobody is listening still.

"Colette has been dismissed and we have been dismissed."

The inquiry said no-one could be sure the two mums' lives would have been saved, even if there had been no shortcomings - a fact NHS bosses have been quick to point out.

But the report identifies several "flash points" where psychiatrists and social workers missed the chance to intervene and potentially save Fiona and Colette's lives.

Psychiatrists even examined Stephenson after he attacked his brother-in-law with a broken glass at a family christening in 2004.

But astonishingly they ruled he was not mentally ill and discharged him from their care. The local crisis team also came under fire for failing to carry out a mental health assessment on Wright after he threatened to slit his partner's throat.

Since the frenzied killings the mental health service in Rugby has been taken over by the Coventry and Warwickshire Partnership NHS Trust.

It has drawn up an action plan of changes and improvements to solve the failings flagged up by the inquiry. These include: n Reviewing the way the county's crisis team responds to serious cases. n Introducing a new system to flag up priority patients and get them immediate appointments.

n Developing new shared records which all practitioners can access to make make sure they understand a patient's background.

n Working closely with police and Warwickshire County Council to draw up a new joint strategy to tackle and prevent domestic violence.

Now it seems bosses have decided to review the progress being made with the action plan ready for next month's inquest into Colette's tragic death.

Colette COLETTE Lynch was stabbed to death by her ex-boyfriend as he held their baby daughter in his arms in February 2005.

The mum of three was knifed through the heart and lungs outside her home in Overslade, Rugby, as she fled from former mental health patient Percy Wright.

Her mother was also stabbed during the attack.

Wright admitted manslaughter on the grounds of diminished responsibility and a judge ruled he should be kept in a secure mental unit until we was no longer a threat to the public.

He was released in April this year after serving less than four years under lock and key.

During the month leading up to her death Colette, aged 24, repeatedly

contacted her GP and the local Crisis Team to complain about Wright's violent and threatening behaviour. She also told them he was hearing voices.

By this time he was already known to mental health services after being seen for 'somatoform' disorders - physical problems which are believed to be caused by psychological issues, in 2004.

Yet Wright was not pulled in even after he broke into Colette's home, assaulted her and threatened to slit her throat.

He missed an appointment with a psychiatrist and the day before he killed his ex he failed to turn up for a mental health assessment.

An independent inquiry branded it a failure to carry out a mental health assesment on Wright.

It also raised concerns about the Crisis Team in place at the time.

Two Warwickshire police officers were also found guilty of misconduct and docked a week's pay for failing to do enough to protect Colette.

Fiona FIONA Stephenson was stabbed 50 times in her own bed by her jealous husband who was convinced she was having an affair.

The 37-year-old mum of three was killed in a frenzied attack by Owen Stephenson in a fit of pathological jealousy because he thought she was leaving him.

Stephenson was later jailed for eight years after a jury found him guilty of manslaughter but cleared him of murder.

The report of an independent inquiry, which has been released by health trust NHS Warwickshire, reveals that Stephenson had a history of terrifying violence dating back more than a year before he killed his wife.

In January 2004 he attacked his brother-in-law with a broken glass at a family christening, causing serious cuts to his neck.

Psychiatrists even said they did not think he was suffering from a mental illness.

After that Stephenson started having fantasies about killing his wife, on one occasion scaring her so much that she fled their house in Hillmorton, Rugby, in her nightclothes and sought refuge at her sister's home.

The inquiry accused the mental health service of not recognising the significance of Stephenson's attack on his brother-in-law, not linking it to his earlier history of mental illness and failing to explore his drunken violence.

The service failed to meet the basic standards of care, the inquiry ruled.

Grave and tragic SANDY Taylor, chief executive of Coventry and Warwickshire Partnership NHS Trust, described the deaths as "grave and tragic".

"A series of significant changes have taken place to NHS services since then, most of which are detailed in the action plans reported to NHS Warwickshire this week," he said.

"We have made a wide range of improvements to our community services as a result, and are about to open a multi-million pound development in Rugby which we believe will continue to strengthen community mental health services in the area."

CAPTION(S):

VICTIM... Fiona Stephenson and killer Owen Stephenson VICTIM...Colette Lynch and killer Percy Wright. Collette's mum Helen (far right) was also stabbed by the ex mental health patient