Sarah Lawson was suffocated by her father in April 2000

The report said the team treating Sarah Lawson, from Worthing in Sussex, was "dysfunctional" and found "failings" in supervision and management of workers.

Miss Lawson died in April 2000 after more than 10 years of manic depression.

The following year her father James Lawson pleaded guilty to manslaughter due to diminished responsibility.

Helped take overdose

Miss Lawson's parents wanted their daughter to be admitted to a secure psychiatric unit after a series of suicide attempts.

In April 2000 she was taken into the Homefields Psychiatric Hospital in Worthing.

But the next day she was ejected for allegedly smoking cannabis and six hours later her father helped her take a drug overdose.

When that did not work, 55-year-old Mr Lawson suffocated her.

James Lawson and his wife were also criticised by the report

After admitting manslaughter he was given a two year suspended prison sentence and two years' probation.

Mr Lawson told police at the time he had taken part in the mercy killing because his family could take no more and he felt the NHS had repeatedly failed to help his daughter.

The case prompted an independent review, with its findings published on Monday.

The report was led by West Sussex County Council's social services department and the Sussex Strategic Health Authority.

Its main findings were:

• There were failings in supervision and management of clinicians in the Worthing Priority Care Trust, especially in the mid-to-late 1990s.

• The Worthing Community Mental Health Team was "dysfunctional" when Miss Lawson was referred to it in August 1997.

• Information was not communicated to the Community Mental Health Team.

• The needs of the Lawson family were not addressed and, as a result, steps were not taken to assess the separate needs of Miss Lawson and of her parents.

The report also identified several positive aspects of Miss Lawson's care including a decision to place her on a treatment order under the Mental Health Act in 1998 which "made an important contribution to the stabilisation of her mental state".

'Learned the lessons'

It said the care she received in 1998 and 1999 was generally of a high standard.

The report also criticised her parents, James and Karen.

It said: "On occasions, Sarah Lawson's mental health was influenced negatively by her parents, and especially by her mother, Karen Lawson."

It said that Mrs Lawson was the "driving force" behind her daughter's care but objected to various proposed treatments.

Mr and Mrs Lawson were also criticised for failing to disclose relevant information about their own backgrounds.

The chief executive of the West Sussex Health and Social Care Trust, Lisa Rodrigues, issued a statement on behalf of all the agencies involved.

She said: "We have learned the lessons arising from this review and have made substantial service changes over the last four years."