Sharon Greenop, 46, was found dead at her home in Troon, South Ayrshire in November 2016, murdered by her sister Lynette Greenop.
A Significant Case Review, published today, said no one could have foreseen her death.
But it identified a series of failings in the care provided by South Ayrshire Health and Social Care Partnership.
The review was led by senior social worker David Crawford and included representatives from South Ayrshire Council, NHS Ayrshire & Arran and Police Scotland.
It said the decision to allow Sharon’s care package to be closed was “flawed” and allowed the circumstances to develop that ultimately led to her death.
And it said the Partnership missed opportunities to raise adult protection concerns regarding Sharon’s wellbeing, which could have resulted in interventions that could have stopped Sharon being abused.
Sharon’s community care package was one of hundreds that hadn’t been reviewed by the Partnership in a number of years despite a statutory obligation and a corporate policy to undertake annual reviews.
The duty system – the initial response for social work referrals – was not fit for purpose and previously identified failings had not been sufficiently addressed.
Record-keeping was extremely poor and hampered by outdated information systems, meaning there was insufficient information about Sharon’s care and wellbeing and it was difficult to manage her case effectively.
The report concluded that there are lessons to be learned from the case.
Professor Paul Martin, independent chair of the South Ayrshire Adult Protection Committee, said: “Sharon’s violent death was a tragedy that no one could have foreseen and our thoughts are with her family and friends.
“It’s clear that steps could have – and should have – been taken by the South Ayrshire Health and Social Care Partnership that could have stopped the abuse she suffered before her untimely death.
“That’s unacceptable and through the Adult Protection Committee and the Chief Officers’ Group – which I report to and includes the chief officers from the Council, police and NHS – I’ll be ensuring that the necessary improvements are put in place as quickly as possible and visibly make a difference for people and communities in South Ayrshire.”
He added: “This review has been very difficult for everyone involved, but especially Sharon’s family, and I hope the outcomes provide some closure for them as they continue to come to terms with their loss.”
In a statement, Sharon’s sister, Diane Hogg, said: “It’s been two-and-a-half years since the brutal murder of my sister Sharon Greenop at the hands of her younger sibling Lynette, a year since the trial and conviction of her murderer.
“I questioned the continuity of care and the system which should have protected Sharon. As the review was progressing and urgent recommendations were being administered, I knew that other areas would take time to change.
“So, with hindsight maybe understanding and insight, looking at the past mistakes it could prevent another family from undergoing the same traumatic experience.
“Hopefully these lessons can and will be learned. Although I have answers, it still leaves an undeniable feeling within myself that just maybe my sister would still be alive if protocols and policies had been followed.”
Tim Eltringham, director of the South Ayrshire Health and Social Care Partnership, said: “We take our responsibilities to protect vulnerable adults from harm very seriously. And while we know it won’t bring Sharon back, we are deeply sorry that we failed Sharon and her family and I have delivered that apology in person to her sister, Diane Hogg.”