A grandmother stabbed to death by a total stranger would still be alive but for a string of failures by mental health staff, a coroner has said.
Sally Hodkin, 58, was killed instantly when she was attacked with a butcher's knife by Nicola Edgington in 2011.
Edgington, who had killed her own mother six years earlier, stabbed Mrs Hodkin hours after being allowed to leave a psychiatric unit.
Coroner Sarah Ormond-Walshe recorded a verdict of unlawful killing.
During the two-week inquest, South London Coroner's Court heard police had taken Edgington to Queen Elizabeth Hospital, Woolwich, after she asked to be sectioned.
She was checked into A&E but grew more agitated and demanded to be taken to Oxleas House mental health unit in Greenwich.
Edgington paced around the waiting room before approaching receptionist Sylvia Rogers and saying: "Is it going to take for me to kill someone, as I've done it before, to be seen?"
Edgington was eventually taken to the unit, but was later allowed to walk out of the building.
Later that day, she killed stranger Mrs Hodkin, 58, with a stolen butcher's knife in Bexleyheath, south-east London.
Concluding the inquest into Mrs Hodkin's death, coroner Sarah Ormond-Walshe said Edgington had been failed by various agencies.
"There was a failure to assess her properly, failure to risk assess her properly, and failure to put her on one-to-one observations," she said.
Ms Ormond-Walshe said another failure was staff failing to stop Edgington from leaving Oxleas House.
"Had one or more of these failures not happened, the death of Sally Hodkin would not have happened," she added.
An independent investigation commissioned by NHS-England in 2017 found NHS and police failings contributed to Mrs Hodkin's murder.
The coroner recorded a verdict of unlawful killing at the conclusion of the two-week inquest.
She said Mrs Hodkin would have died instantly from wounds to the neck.
Edgington was jailed for life with a minimum term of 37 years in 2013 for the murder of Mrs Hodkin and attempted murder of another woman on the same day.
She had been released from a secure psychiatric unit in 2009 despite an order she be detained indefinitely after stabbing her mother Marion to death in 2005.