ipccPolice officers failed to carry out checks on a psychiatric patient who went on to commit murder, an investigation has found.

In the hours before the murder Edgington made five 999 calls to police saying she wanted to be sectioned under the Mental Health Act because she was a danger to those around her. Four of those calls were made while she was within the Accident and Emergency department of Queen Elizabeth Hospital, Woolwich, waiting to be seen by a mental health team.

Edgington had been taken voluntarily to the hospital as a place of safety by two Metropolitan Police Service (MPS) officers who responded to the initial 999 call. The hospital reported to police that she had absconded about 90 minutes before the attacks in Bexleyheath.

The IPCC investigation found a number of failings in policing going back over two years. This included the local borough police in Greenwich not being notified by the Mental Health Casework Section of the National Offender Management Service that Edgington was living in the area following her release from an indefinite hospital order in 2009 and was a multi-agency public protection arrangements (MAPPA) eligible offender.

Also, MPS officers and police staff did not carry out a Police National Computer (PNC) check on Edgington during their interactions with her on the day of the murder, which would have alerted them to her previous conviction for manslaughter.

The IPPC report added that officers missed an opportunity to use their powers under section 136 of the Mental Health Act when Edgington tried to leave the A&E department shortly after she arrived with police.

Finally, Edgington’s second 999 call from the A&E department was downgraded because she was considered to be in a place of safety and an officer was not asked to return despite Edgington saying she could be very dangerous. The police only contacted the hospital after a fourth call had been received.

IPCC commissioner Sarah Green said: “This tragic case has robbed a family of a much-loved wife, mother, grandmother and friend and my thoughts again go out to Sally Hodkin’s family.

“While our investigation found that no police officers or staff breached the code of conduct, it is of great concern that no PNC check was carried out which would have immediately alerted them to Edgington’s violent history.

“Without this PNC check, both the police and staff at Queen Elizabeth Hospital, Woolwich were without crucial information which may have influenced their future decisions, increased the urgency of the situation and could have escalated the medical attention she was given.

“We also found that when Edgington tried to leave the hospital shortly after she arrived, there was a missed opportunity for the officers to use their powers under section 136 of the Mental Health Act which would have provided medical staff with the opportunity to detain her.

“However we note that nursing staff at the Oxleas Centre also decided not to use their powers under the Mental Health Act 1983 to detain Nicola Edgington on the basis that she was voluntarily consenting to admission, and that it was from the care of the mental health unit that Nicola Edgington absconded to commit her terrible crimes.

“It is to be hoped that both the MPS and the Oxleas NHS Foundation Trust will learn lessons from this tragic case to improve the handling of high risk individuals such as Nicola Edgington in the future.”

Marjorie Wallace, chief executive of mental health charity SANE, said: “This case is a truly shocking indictment of psychiatric services and the failure of all agencies involved to protect both a patient and the public. Nicola Edgington was a known risk having killed her mother, yet in the opinion of one psychiatrist she could be safely treated in the community.

“Such supervision in the community relies on a network of communication which can all too easily fragment when a crisis arises. It is unfair on everyone involved, including the police who should not be in the position of assessing the risk posed by someone who could be so severely mentally disturbed.

“The most worrying aspect of this is that it could have been prevented. Edgington told people she was not taking her medication and had become a danger to herself and others, yet felt she had to prove it to be taken seriously.

“If the system cannot cope with the relatively few cases of people with mental illness and a history of violence, how can we prevent the stigma which blights the lives of so many thousands who suffer from mental illness and are never violent?”