Harold Philpotts death: Treatment 'could have been improved'
The care and treatment of a mentally ill man from Cornwall, who died after a fire it was believed he started, could have been improved, a report says.
Harold Philpotts, who had depression, died in 2010 after a fire at his Newquay home. His wife and son were found dead at the scene.
The independent report said better risk assessments should have been carried out.
It added the agencies' work did not lead directly to the other deaths.
Mr Philpotts, 47, was diagnosed with conditions including depression, delusion and paranoia and believed friends, family and others were conspiring to kill him, an inquest last year was told.
He was under the care of a mental health team but staff did not believe he was a risk to his wife and son.
He died of burn injuries eight days after the house in Trevarrian burnt down in January 2010.
His son Ben, 10, was found in the house with head injuries. Mr Philpotts was believed to have bludgeoned him to death before setting the fire.
The body of 44-year-old Patricia Philpotts was found in a bedroom where the fire, which involved petrol, started.
The inquest ruled that Ben was unlawfully killed, and recorded open verdicts for Mr and Mrs Philpotts.
The new Health and Social Care Advisory Service report said there should have been better risk assessments of Mr Philpotts, particularly concerning violence, alcohol and drugs.
It added that there should have been better sharing of information between agencies, such as police and social services; plus a more challenging approach when service users failed to engage.
Records access 'improved'
Report author Ian Allured said: "No one agency had all the information. Had that been known, there might possibly have been a slightly different outcome.
"But we couldn't say that any one person or any one agency was responsible."
The Cornwall Partnership NHS Foundation Trust said lessons had been learned.
Medical director Dr Ellen Wilkinson said: "I'm never going to be able to say that something like this is never going to happen again.
"But what have tried to do is strengthen our processes internally.
"We have an improved record system allowing access 24 hours a day."