Kingston Council failed to help woman who was later murdered
An independent report has found "unacceptable levels of complacency" at a council which failed to help a woman who was later beaten to death.
Charito Cruz, 37, was bludgeoned with a hammer by her partner Muhammed Niazi, in front of her two-year-old daughter in September 2011.
The author of the Domestic Homicide Overview Report said she was "sad and depressed" at what she had found.
Kingston Council said it welcomed the review and had made changes.
'Lack of urgency'
Niazi, 32, was jailed for life in December 2012 with a minimum term of 12 years in prison, after he was found guilty of murder.
Report author Davina James-Hanman found the council had ignored two requests from the NSPCC to visit the family home.
The charity was concerned Niazi's behaviour was becoming increasingly erratic.
Niazi, who wrongly thought his partner had rekindled an old relationship, had taken a paracetamol overdose.
He also watched pornography in front of his daughter and let her play with cigarettes.
He went on to smash his partner's phone with a hammer, the same weapon he later used to kill her.
Despite being informed of this, team managers at children's social care did not organise a visit.
The report concluded: "It is difficult to see how this [the murder] could have been predicted but the question remains open as to whether more robust responses may have prevented (Ms Cruz's) death."
A mental health assessment on Niazi by South West London and St George's Mental Health NHS Trust was found to be inadequate.
The Domestic Homicide Review has said the 2011 assessment which concluded Niazi "was not a danger to himself or others", was concerning because "safeguarding children and potential domestic violence risks were not assessed in detail".
Ms James-Hanman said: "The lack of urgency in the responses from children's social care were indicative of a culture of complacency which is clearly unacceptable within child protection."
She added: "Whilst it's very difficult for everyone to be on the ball 100% of the time, we are talking about very vulnerable women and children who do need that level of vigilance."
In January 2013, a whistleblower, Olivia Butler, who was working as interim head of children's social care at the time of the murder, told BBC London mistakes had been covered up.
She claimed the council had rejected her advice to discipline two members of staff for failings in the case and she was not supported in trying to improve the department.
Ms James-Hanman said a possible cover-up remained an "open question" - but agreed with Ms Butler on a number of allegations she made.
Her report criticises "retrospective record keeping" at the council, which meant details of contact with Ms Cruz and with other agencies were only put on the computer system after the murder.
Ms Butler said: "I'm relieved that she [the report author], a person with such experience and expertise and integrity, has found some of the same things that I also found that were also extremely worrying to me, and that she's had the opportunity to put that into the public sphere."
The council says it has changed the way information is recorded and appointed new management since the murder. The team leaders mentioned in the report have since left the borough. They were never disciplined.
An Ofsted inspection has not been carried out since the implementations were made. The last two found children's services to be inadequate.
Leigh Whitehouse, the director of finance at the council and chair of the Safer Kingston Partnership, said practices had not been "as effective and tight as they could have been".
He added: "That's definitely something that's been addressed as part of the work undertaken since the Ofsted inspection."
He said: "We want, on behalf of all the agencies in the Safer Kingston Partnership, to offer our deep condolences for their loss and to also say sorry for the tragic events that led to this woman losing her life and her daughter losing her mother."
He denied there had been any deliberate cover-up.