Michael Martin was attacked with a pickaxe in his home

Matthew Martin killed his father, 56-year-old Michael Martin, with a pickaxe at his home in Almondsbury only three months after his release from Exeter Prison in 1999.

The New North Road jail was among a number of agencies involved in the care and treatment of Matthew Martin.

The inquiry on Thursday said no single action or omission was to blame, but it highlighted a number of shortcomings in Matthew Martin's care and treatment, both during and after his short time in jail.

We give our assurance that the recommendations in the report will be fully implemented Ian Sinnett, prison healthcare cluster manager

Michael 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, the independent inquiry concluded.

Officials at the Devon jail said new procedures were being introduced to try to prevent such a tragedy happening again.

Prison healthcare cluster manager Ian Sinnett said: "We would like to offer our deepest sympathy to Mr Martin's family.

"We give our assurance that the recommendations in the report will be fully implemented.

"Some reports that prisoners prepare with their solicitors are confidential between them, and we are implementing procedures where we can ask them early for their consent for healthcare professionals to have that information.

Appropriate assessment

"In addition, there is �168,000 of new funding to develop mental health in-reach services which will ensure the appropriate assessment, treatment and through care of prisoners with mental health needs.

"It will specifically address those who pose particular risks."

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 inquiry 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.