Michael Martin was attacked with a pickaxe in his home

Matthew Martin attacked his father, 56-year-old Michael Martin, with a pickaxe at his home in Almondsbury, south Gloucestershire, in 1999.

Mr Martin had been afraid of his 25-year-old son for some time - he had hidden knives from him and even programmed 999 into his mobile phone.

But despite his father's numerous pleas for help, the paranoid schizophrenic slipped through the healthcare system which could have stopped the killing, an independent inquiry concluded.

It is especially cruel that the late Mr Martin, as the caring parent, should have become the victim of his own mentally ill son. Gillian Downham inquiry chairwoman

Matthew Martin pleaded guilty to manslaughter on the grounds of diminished responsibility at Bristol Crown Court in 2000 and was sent to a secure unit under the Mental Health Act.

The three-year �150,000 inquiry found that although no single error was responsible, a number of missed opportunities and better communication between care agencies "might have diverted him from killing his father".

Its report listed a number of blunders including missing prison records, a shortage of social workers and Martin being "mysteriously" deleted from a computer database which would have triggered a check on him.

He was also released back into the community from Exeter Prison after being on remand for firing an airgun at someone in Plymouth, with no psychiatric assessment, no home address, no medication and no planned medical appointments.

'Acutely mentally-ill'

Martin had been diagnosed with schizophrenia in 1996, but went some 18 months without medication or real help even jumping out of a car at one point to avoid his father taking him to hospital.

He had been in prison three times and lived at numerous addresses throughout the South West, degenerating into a muttering, filthy man who often walked barefoot through the streets of Bristol.

Inquiry chairwoman Gillian Downham said Matthew Martin's story was tragic but typical.

He was a young, acutely mentally-ill man who had "disengaged" from the system, having a life where he slept rough, begged on the streets and was involved in petty crime and drugs.

Avon, Gloucestershire and Wiltshire NHS Strategic Health Authority's report told how his mother had died in an apparently suicidal car crash when Martin was only eight and he often referred to gravestones as "his real family".

"It is especially cruel that the late Mr Martin, as the caring parent, should have become the victim of his own mentally ill son," said Mrs Downham.

The inquiry concluded: "Matthew Martin received care and treatment from many professionals who individually gave of their best.

"There were nevertheless weaknesses in the form of many missed opportunities."

The inquiry made a number of both local and national recommendations, some of which the NHS Trust said it has already taken on board and others it will be working on.