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An independent inquiry into the care and treatment of a diagnosed schizophrenic man who strangled his pregnant girlfriend has urged Wiltshire social services to review its procedures.

Richard Gray attacked Ginny Sivil while she was in the early stages of labour with his child. Both Sivil and the unborn baby were killed. Gray was admitted to Broadmoor hospital and their surviving two children now live with Sivil's parents.

A number of serious criticisms are made in the report, commissioned by Wiltshire social services and Wiltshire health authority, but no single failure of services or professional care is blamed.

Director of social services at Wiltshire council, Ray Jones, said that despite a whole range of mental health services and supervision Gray had received over 14 years, it was impossible to predict that such an event would occur.

"This is not a story about someone who got lost in the system. It is an instance where the complexities and difficulties Gray presented in the end led to a tragedy which we were unable to prevent," Jones said.

The report highlights concerns over the care of conditionally discharged patients within local psychiatric teams, and multi-disciplinary communication.

"Key information concerning Richard Gray's thoughts of killing Ginny Sivil and his family did not become known to all professionals involved, and did not reach the office dealing with the case. This was despite many opportunities for multi-disciplinary exchange of information," the report says.

There was no planned or co-ordinated arrangement for risk assessment and, despite regular drug use by Gray, there was no substance misuse service available locally.

Wiltshire social services was responsible for his care throughout his contact with adult mental health services.

The report adds that Avon and Western Wiltshire Mental Health Care NHS Trust and social services should review procedures for multi-disciplinary meetings. It concludes there should be a joint procedure for the assessment and management of risk and any named person thought to be at risk from a patient should be informed.