The murder of a teenage girl by a fellow care home resident fascinated by necrophilia could have been prevented, an inquiry has found.
Melissa Mathieson, 18, was strangled by Jason Conroy in 2014 at Alexandra House in Bristol, a home supporting people with autistic spectrum disorder.
Conroy, who once tried to strangle a teacher so he could abuse her, planned to drag the teenager's body back to his room and have sex with her.
He had also attempted to kill his mother by putting a duvet over her head for the same reason.
Hours before she died Miss Mathieson, who ADHD and autism, had complained to staff that Conroy was stalking her.
Conroy, now 21, was jailed for life in 2015 for murder and told by a judge at Bristol Crown Court he would serve at least 19 years before he could be considered for parole.
Judge Graham Cottle said the murder was clearly sexually motivated, adding that Conroy (pictured) had exhibited "sexual deviancy of the most worrying kind".
The Bristol Safeguarding Adults Board has now published a serious case review into the teenager's death, which highlighted some areas of practice that needs to change, and makes national recommendations.
Louise Lawton, chairwoman of the board, said: "Melissa's death was particularly shocking and had a profound impact on everybody involved.
"The loss that Melissa's family have suffered is immeasurable and their involvement in this process has been essential to creating a full picture of Melissa's life and the circumstances surrounding her death.
"The themes arising are relevant across the country and many of the recommendations for the board focus on raising issues at a national level.
"The review looks at how agencies work across county borders, the transition between children and adult services and the use of risk assessments.
"How potentially dangerous people are cared for and managed is another area of focus, as is ensuring organisations are using professional language which both sides understand when individuals are moving between services.
"Information sharing is also shown to be vital.
"Sadly, the review found that Melissa's death could have been prevented if better processes had been in place.
"At the heart of this review is a vulnerable young woman who lost her life and I hope that the findings will help stop something like this from happening again."
Miss Mathieson's father, James, from Berkshire, said: "The agencies concerned need to be looking inward at themselves critically, firstly to find and rectify all faults, but they also need to listen to families and look for ways to improve their services to prevent any similar disaster befalling any other family.
"We feel we have been treated with contempt and arrogance before and after Melissa's death by the local social services, with no thought about the stress and trauma the family had been put through.
"There are far too many mistakes being made by all services around the country for this to be just an isolated case.
"Focusing just on the murder will not prevent this mistake happening again.
"I hope that Melissa's death will be a turning point in how the services treat families of autistic young adults, young adults with mental health issues and that Melissa's death is used to change attitudes of all services and that they help families to cope before there is a breakdown of trust.
"We do not want Melissa's short life to have been for nothing."
Meanwhile, the Independent Police Complaints Commission has made recommendations into how West Mercia Police dealt with the allegation that Conroy assaulted his teacher in 2013.
The IPCC said the force should have recorded the incident as a crime when it was reported.
The watchdog said an officer, who was informed by the school of the allegation, would have had a case to answer for misconduct for not recording the incident had they not retired.
Conroy was later found guilty of attempting to cause grievous bodily harm.
Another investigation into an incident in Devon involving Conroy in 2009, following which he was arrested for allegedly assaulting a member of school staff, found Devon and Cornwall Police had responded appropriately.
Copyright (c) Press Association Ltd. 2017, All Rights Reserved. Picture (c) Avon and Somerset Police.