Care staff failed to act on a host of warning signals in the weeks and months before a psychiatric patient murdered a grandmother, an inquest has heard.
Nicola Edgington (pictured) virtually decapitated Sally Hodkin with a butcher's knife in Bexleyheath, south-east London, in October 2011, six years after killing her own mother.
She was discharged from the Bracton Centre mental health facility after just three years in 2009 to live in the community, despite an order that she be detained indefinitely following the killing of her mother Marion.
The diagnosed schizophrenic had threatened at least two people with knives after her discharge, and was smoking high-strength "skunk" cannabis leading up to the murder, South London Coroner's Court heard.
She also made a number of emergency calls to police about "crackheads" stealing from her flat just days before killing the 58-year-old.
Consultant psychiatrist Janet Parrot told the inquest skunk use "can be associated with a catastrophic relapse" in somebody with a pre-existing illness.
Around two weeks before the killing, Edgington believed she had suffered a miscarriage, which was significant because she had a termination against her will shortly before killing her mother, the inquest heard.
On September 29, she sent a Facebook message to her brother telling him about it and saying she wanted to reconnect.
The message also mentioned their mother, with Edgington saying: "No-one's taking care of me like she would."
Her brother replied on the same day: "You stabbed her to death and left me to find the body. Good news about your miscarriage ... do us a favour and slit your wrists."
Edgington had also threatened her husband with a knife on a trip to Jamaica in 2010, which was not noted in the trip report to the Ministry of Justice (MoJ), the inquest heard.
Both forensic social worker Elizabeth Lloyd-Folkard and Dr Parrot, who were part of the team responsible for her care, said the incident couldn't be substantiated and so was not passed on.
Ms Lloyd-Folkard said: "At the time I felt it wasn't corroborated. He [the husband] wasn't following it up and saying he wanted to make a complaint."
Some months later in August, Edgington's boyfriend told police she had been drinking alcohol and had threatened a clubber with a knife.
Mrs Hodkin's son and solicitor, Len Hodkin, said: "There are no records of any conversations taking place regarding these issues.
"This is the second incident where she's allegedly threatened someone with a knife - a woman who brutally killed her own mother with a knife."
Dr Parrot replied: "We had no evidence she had a knife. It was in relation to a boyfriend arrested on suspicion of breaking into her flat so we would need some corroboration to take that further."
Contact with family members, substance misuse, and issues around pregnancy were noted in psychiatric reports as high-risk factors that could affect Edgington's mental health, the inquest heard.
Mr Hodkin told the inquest: "All of those risk factors were present in the two to three weeks leading up to October 10.
"It's not coming with the benefit of hindsight, this information was available to you and other members of the multi-disciplinary team at the time."
Ms Lloyd-Folkard, told the inquest that around a week before the killing she had "no cause of concern about her state of mind".
The now-retired mental health worker, who had known Edgington for around six years, said: "All of those things were dealt with in counselling.
"We wouldn't have left her feeling like that if the counselling hadn't been effective.
"I didn't know at the time that she had used skunk cannabis.
"That was the most high-risk factor. She knew if she used it would send her into a psychotic episode."
A damning report last year concluded a catalogue of NHS and police failings led to Mrs Hodkin's murder.
On the day of the killing, Edgington repeatedly called police to beg for help and told A&E staff she needed to be sectioned and felt like killing someone.
She told A&E staff that she had not slept in three weeks and had stopped taking her medication, the inquest heard.
Although she was taken to Oxleas House mental health unit in Greenwich to be admitted, she was able to freely walk out of the unit to commit the crime.
The inquest continues.
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