A mentally-ill man stabbed his niece to death before turning the knife on himself in a Mansfield caravan park, an inquest has heard.
The bodies of Richard Thompson, 66, and Lisa Butler, 48, were found by a family friend in a caravan on the Tall Trees mobile home park, off Old Mill Lane, Forest Town, on August 28 last year.
Coroner Mairin Casey warned members of their family that the post-mortem contained details that are "unavoidably graphic and terribly distressing" when she opened the inquest in Nottingham, on Thursday July 25.
She said: "I want to know what happens if someone with Richard's problems who is living in the community and has stopped taking his medication, what impact would this have and what risk it would pose to others.
"There is a risk of other future deaths if I find failings here. This was not a routine attack this was a frenzied attack."
Home Office pathologist Dr Michael Biggs carried out the post-mortem on Mr Thompson, which found parallel wounds on his head, chest and abdomen, as well as scars on his forearms, and self-inflicted neck wounds, and died "relatively rapidly from blood loss".
Forensic scientist Geraldine Davidson, who carried out the post-mortem on Mrs Butler, said the blood patterns were "indicative of Lisa being stabbed in the kitchen doorway and falling to the floor until she was found and attempts to resuscitate her were made."
She died from two stab wounds to the chest and other injuries over her body.
Detective Sergeant Rob Wells, of the East Midlands Major Crime Unit, said a police officer arrived at the scene six minutes after ambulance crews raised the alarm at 10.03pm.
He described how the officer saw two people lying on the floor and the then-partner of one of Mrs Butler's daughters doing CPR with blood on his hands.
He said: "Lisa was very much involved in helping him get rehoused to the caravan park. She and her family helped him once a week.
"Lisa was concerned he hadn't been taking his prescribed medication," said DS Wells. "A friend of Richard's said he was "quite low" and not settling in" at Tall Trees."
The inquest heard Mr Thompson attempted suicide in December 2017 and was admitted to the Kingsley ward, at Millbrook mental health unit, in January 2018, when he was diagnosed with late-onset schizophrenia and mild cognitive impairment.
"Why was he deemed safe enough to leave the hospital?" the coroner asked.
"I think they thought this was his first episode and Lisa was so caring and willing to have him back home and because he was very guilty about what he had done," said Dr Isu Katuwawela, who treated him at Millbrook.
"It reads to me that it was OK for him to go and stay with Lisa. Despite using a very violent method to hurt himself, he very quickly settled on to the ward."
Dr Katuwawela said: "I stressed the importance of taking his tablets. I said the medication would help lessen the significance of his feelings.
"I would ask - do you think people are watching you? Are you eating, sleeping? What does his house look like? Does he look haggard or distressed? Is he talking calmly?"
Psychiatrist Dr Godfrey Akpoyibo said he met Mr Thompson on May 29, when he appeared subdued and vague and was "unduly concerned about a flower coming over his wall".
He said: "I explained that it might be wise to consider a more suitable medication. There is no evidence of dementia. I will reassess in four months. There were no issues of significant concern at the time."
Ms Casey said: "I find it quite alarming that this issue is properly flagged up in May, and never revisited after May 29 by the psychiatrist or the community psychiatric nurse."
Karen Hampson, who manages the community mental health services for older people, said: "There was a lack of enquiry around Richard's mental health - thinking about things like relapse indicators.
"Maybe we could have sat down with him so we would have a clearer ideas of when he was relapsing."
Ms Casey said: "We cannot look at this case and say Lisa and Richard could have been here today - even if the very best practise had been adhered to.
"It is part of his condition. It is impulsive. It is unpredictable."
The coroner praised the work of the psychiatric nurses who looked after him on a weekly basis.
In her conclusion, Ms Casey said Mrs Butler's death was caused by unlawful killing and Mr Thompson took his own life.
"It is not possible for me to determine whether he had the capacity to commit suicide, but he did die by his own hand," she said.
She said there was no evidence that advice was given about the potential impact of Mr Thompson stopping his medication.
She said Dr Akpoyibo made a serious error of judgment because he didn't plan another review in mid June.
"I cannot and do not find that if optimum care had been provided, this tragedy could have been avoided on that fateful day," she said.
"It does not help the family to learn that intervention might well have made a difference in this case.
"But there were failures in care and missed opportunities and learning opportunities for the mental health team.
"It is my sincere hope that these lessons will be learned and embedded."
She praised Lisa Butler as a "selfless and generous niece who lost her life".