Social workers could have stopped the abuse of a woman before she was murdered by her sister, a review has found.
Sharon Greenop, 46, was killed at the home she shared with her sister Lynette in Troon, Ayrshire, in November 2016.
Lynette Greenop, 40, was sentenced to a minimum of 23 years in jail at the High Court in Glasgow.
A Significant Case Review was carried out to consider social work's involvement in the case.
It found that responsibility for Sharon's death lay with her sister, and that no one could have foreseen her murder.
However, it also identified a number of areas where the South Ayrshire Health and Social Care Partnership (HSCP) could have acted to help prevent her death.
It has also called on HSCP to "make an immediate decision in relation to the outstanding disciplinary issues resulting from this case".
They findings of the report included:
- The "flawed" decision to allow Sharon's care package to be closed allowed the circumstances to develop that ultimately led to her death
- The Partnership missed opportunities to raise adult protection concerns regarding Sharon's wellbeing
- Sharon's community care package was one of hundreds that had not been reviewed by the Partnership in a number of years, despite a statutory obligation to do so
- The duty system 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- Record-keeping was extremely poor and hampered by outdated information systems
- Management practice was poor in places and did not support efficient and effective working practices.
Prof Paul Martin CBE, independent chairman of the South Ayrshire Adult Protection Committee, said Sharon's violent death "was a tragedy that no one could have foreseen".
He added: "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... 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.
"The Committee will monitor progress closely and seek clear evidence from the Partnership to ensure we know - for a fact - that services are improving and continue to protect vulnerable people from harm.
"This will mean we can all be reassured and can have confidence in the social work services delivered to vulnerable people across South Ayrshire on a daily basis."
'Body lay for weeks'
The murder trial heard how Sharon Greenop's body may have lain for weeks before being discovered by police.
A pathologist told the jury that she sustained 19 rib fractures and additional fractures to the neck, but the cause of death was "unascertained".
Police had been alerted after a neighbour complained of a smell coming from the women's home.
But when officers turned up at the house, they were told Sharon was "sleeping".
The jury heard how Lynnette Greenop later confessed to a former neighbour: "Aye, I did it."