A violent prisoner who killed a woman while drink-driving had "no new formal risk assessment" before being released on parole, a damning report has found.
Donovan Kitching committed 33 offences in custody before he knocked down 62-year-old Gwen Valentine in April 2014.
The Karran Inquiry highlighted "a total lack of coordination" and "confusion" between the prison, parole board and police.
The Department for Home Affairs said it was working to address the findings.
Kitching, who had 44 previous convictions, had served almost two-thirds of a six-year sentence for aggravated burglary and robbery when he was granted parole on 2 April 2014.
Less than a month later, he struck and killed Ms Valentine, from Winchester in Hampshire, as she walked on the Tholt-y-Will Road.
He had no valid licence and was fleeing police at the time, as he was still serving an eight-year driving ban and had just been arrested for drink-driving.
Kitching pleaded guilty to causing Ms Valentine's death by dangerous driving and was sentenced to 10 years and 72 days in jail.
An investigation of the parole system was ordered after the court was told of his "shocking record" while in custody, which included assaulting another prisoner and threatening a prison officer.
In his report, Mr Karran said while no-one "broke any law, rule or regulation" in relation to Kitching's release, there were a number of issues with "the practice that had evolved" on the island.
He said a probation officer had recommended Kitching be freed because it was only three months to his automatic release date and there was "little to be gained" by keeping him in custody.
Another said, had she known details of his offences in prison, she would have reconsidered her decision to support parole.
Alongside the lack of a new risk assessment ahead of his release, the report said a key meeting to review his licence conditions and plan a "probation regime" did not take place due to the speed of his release and there was a "total failure" in the monitoring of him after release.
It also gave details of Kitching's previous convictions, which included:
- Theft, assault and criminal damage to a cell in 2000
- Assault of a police officer and breaching probation orders in 2001
- Threatening a police officer in 2002
- Resisting a police officer and driving while disqualified in 2009
Ms Valentine's son Stuart said it was a "profoundly shocking report" which showed there had been "a systemic failure, not an individual one".
"Nobody has resigned or been dismissed, and they should not - this is sometimes what happens when good people imperfectly follow flawed processes," he said.
"Failing to prevent the circumstances that led to a crime is not remotely the same thing as committing it, but that does not make this in any way acceptable."
He added that of the 37 recommendations, 30 had been accepted by the authorities, two had been rejected and five were as yet unresolved.
Juan Watterson, who was Minister for Home Affairs at the time, said improvements in the parole system had already been made.
"Whilst I may have my regrets about the decision that I made was one of a series of circumstances which cost an innocent lady her life, it is right that politicians ensure that the policy framework, overseen by the home affairs minister, balances justice, rehabilitation and accountability," he said.
"I was glad that I could evidence critical thinking and an evolution of the parole process during my tenure and I am sure that this is something that will be further developed in the years ahead."
Bob McColm, the governor of Isle of Man Prison, said the report highlighted a series of "embarrassing" failures, including "confused communications" between the prison, parole board and police.
"I can't guarantee something like this will never happen again but I can guarantee that the system is improving," he added.