No formal risk assessment was done on a man who beat a fellow care home resident to death, a review has found.
Alexander Rawson attacked 93-year-old Eileen Dean with a metal walking stick at a care home in south-east London. Mrs Dean suffered catastrophic injuries to her head and body and died later in hospital.
A review found Fieldside Care Home in Catford did not provide the specialist mental health services that Rawson - who had a history of violence - needed.
Rawson, who had a history of mental health problems caused by alcoholism, was 62 when he was placed in the home a few days before Christmas 2020.
He was put in the room next to Mrs Dean and, in the first week of 2021, he went into her room at night and attacked her.
In a review published on Friday, the Lewisham Safeguarding Adults Board said Rawson had been moved into the home after being an inpatient at a psychiatric unit run by the South London and Maudsley NHS Foundation Trust.
The care home was the only place that agreed to take him after his discharge from hospital.
In the months before he was moved into the care home, Rawson was involved in at least 34 recorded incidents of violence or threats to patients and health staff, including a threat to kill.
Before he was placed in the home, no attempts were made to find out whether Rawson had come into contact with the criminal justice system over his behaviour, the report found.
It states that the care home had asked about the risks Rawson posed before they took him and had been reassured by a social worker and medical staff.
Source: BBC News, 12 November 2022