A report has drawn up an action plan for improvements after uncovering a series of issues in the care of a man who killed his wife and then himself at their Sunderland home.
The independent investigation into the work of Northumberland, Tyne and Wear NHS Foundation Trust was carried to look at the care and treatment of James Stokoe, who had suffered periods of depression dating back to 1987.
The 79-year-old stabbed his wife to death at the couple's home of 48 years in Hylton Castle on May 1, 2013, before taking his own life.
Retired blacksmith Mr Stokoe, who was being treated for bladder cancer, had made a previous attempt to commit suicide and had told care workers he had "demon thoughts."
These included thoughts about harming his wife, but he said he had no plans to act on them.
In the days leading up to their death, community psychiatric nurses details strains between the couple, with Mr Stokoe anxious and was "suffering thoughts which he found difficult to describe" failing to give an answer when he was asked if he was having thoughts of harming himself or others.
Issues highlighted in the report include a lack of communication between health teams, including his psychiatrist, GP and City Hospitals Sunderland NHS Foundation Trust who failed to share details of his depressive illness and martial disharmony, which was important in his diagnosis, management and treatment, as well as the risk of suicide.
The report states this "represents a significant missed opportunity by staff" with a recommendation made about how records are kept, as well as stress put on how information should be shared.
It found the trust has not considered the needs of Mr Stokoe's carers or family, with relatives raising the issue of a lack of support and a lack of a plan to support the couple.
The trust has since introduced a new process to help carers.
It also states Mrs Stokoe, also 79, had not been offered any support services, with a lack of thought given to how she could help staff, beyond being told to phone with any concerns, with their daughter-in-law key in his care - she went to the couple's home when they could not be contacted, when it emerged they had died.
The trust's action plan details how supervision of caseloads is in place, with six-monthly audits to take place, while additional training has been proposed with team.
A spokesman for the trust said: “We would like to thank the authors of this report for their time and hard work.
"The report highlights that the deaths were not predictable or preventable by our staff.
"Once again, our thanks to all involved in compiling this thorough and professional report.
"Our thoughts, and sympathy, remain with the family.”
A domestic homicide review released in September 2014 found the deaths "may have been preventable."
That report, carried out by Safer Sunderland Partnership, said Mrs Stokoe had remained “invisible” to agencies.
The causes of her many falls which had been recorded had been put down to her age, while it also found staff across agencies were less likely to consider older people as potential perpetrators of domestic abuse.
It concluded that the killing could not have been predicted but it recommended more is done to raise awareness of the potential for domestic violence by older people.