Tammy Little's friends say she was concerned about her partner

An independent panel last week found the South West Peninsula Health Authority made a catalogue of failures when dealing with Errol Leong, 38.

He admitted throttling Tammy Little, 36, in Hayle Towans on the grounds of diminished responsibility in 2001.

He had been released from custody the day before, even though he had been psychiatrically assessed and threatening to make Ms Little "black and blue".

The inquiry panel criticised the management style of the Cornwall mental health team, supervision, training and communication.

In return, the South West Peninsula Health Authority agreed to make a number of urgent changes to prevent a similar incident.

By working together we can make sure that the risk to people is minimised Celia Inman, Cornwall Domestic Violence Forum

But Celia Inman, manager of Cornwall Domestic Violence Forum, said the changes did not go far enough, and they should have been consulted.

She said: "I think that with domestic violence, no one agency can take it on board.

"It has got to be multi-agency working. Different people have different skills and by working together we can make sure that the risk to people is minimised."

Charlotte Lee, one of Tammy's friends, said: "Tammy phoned Errol's mental health officer several times to say she was concerned about his behaviour and that he wasn't taking his medication.

"It took him two or three weeks to get back in touch and the message was 'Don't worry.'

"There was just no follow up at all. They just didn't seem bothered by his state of mind."

The South West Peninsula Health Authority has already implemented a number of changes to the way mentally ill patients are cared for.

These include a review of policies and procedures, improvements in training and qualifications and better integration between all mental health providers.

Two years ago Leong pleaded guilty to manslaughter on the grounds of diminished responsibility and a judge at Exeter Crown Court ordered him to be detained indefinitely.