Tragic Sarah Lawson - helped to die by her father in a mercy killing in 2000 - was failed at almost every level, according to a critical report into her care.

A review into the circumstances of 22-year-old Sarah's death, whose findings are published today, reveals a service in such turmoil it was unable to cope with a family in crisis.

Sarah's father James, 55, walked free from court in 2001 after admitting killing his daughter to end her suffering.

The family's attempts during the previous four years to get adequate treatment for their daughter's depression failed because the service was at times "woefully inadequate."

The study, commissioned by Surrey and Sussex Strategic Health Authority and West Sussex County Council, highlights a catalogue of concerns.

It concludes that in the early stages of Sarah's care "it would be difficult to envisage a more unsatisfactory situation."

As incidents of self-harm became more frequent from 1997, Sarah spent time in clinics, day hospitals, psychiatric units and rehabilitation centres under the overall management of the former Worthing Priority Care NHS Trust.

A GP drew up a 12-month programme to treat her as an outpatient in 1999 but by then Sarah was too ill to see it through.

Her condition took a serious downturn in April 2000. She attempted suicide after a family crisis and was admitted to casualty at Worthing Hospital.

She was transferred to Homefield Psychiatric Hospital in Worthing but was ejected after she was found in possession of cannabis. Six hours later, her father killed her.

The review's overarching conclusion is that by the time the health service realised how serious Sarah's condition had become, a wall of mistrust, verging on outright hostility, had built up between care workers and her family.

The strategic health authority has refused to publish the full report, almost 300 pages long, partly because of patient confidentiality.

Key findings of its 23-page synopsis are:

The Worthing Community Mental Health Team (CMHT) was dysfunctional in 1997 and Sarah's treatment was fragmented
Clinicians treating Sarah were not properly supervised
Sarah's mother Karen became the driving force in her care but refused to give crucial information concerning her own medical past; she also rejected some treatments, which could have helped her daughter
The Lawsons' concern for their daughter was experienced as hostility by professionals
Therapists depended on memory rather than written records to recall previous sessions
No one formally examined Sarah before she was discharged from Homefield in April 2000; had the duty consultant known the full facts, he would not have released her
The report lays the overall blame for the failures at the hands of the senior trust managers and senior professionals, particularly the psychiatrists and nurses.

It singles out the efforts of GPs and social workers who struggled to give Sarah proper care in a climate of confusion.

But the Lawsons are also criticised for their actions in the progress of their daughter's illness and for their refusal to contribute to the investigation afterwards.

James Lawson, who was given a two-year suspended sentence in 2001 after admitting manslaughter, today said the review panel was "not independent or legal".

At home in Georgia Avenue, Worthing, he said: "The report doesn't surprise me at all. Sarah was in the wrong place at the wrong time. Looking back, I have no regrets. You deal with life the way it is."

Mr Lawson, who works in the building industry, said legal action planned against the care trust at the time of Sarah's death had been abandoned.

He said he was horrified at suggestions the family had influenced Sarah's illness.

He said: "My daughter was loved by her mother and father. Any parent would do anything they possibly could to help their child.

"To read an inference that we influenced what was happening to her is an abomination."

"When my wife tried to reach out and get help for Sarah she was knocking against a big brick wall."

Lisa Rodrigues, chief executive of West Sussex Health and Social Care NHS Trust, which has replaced Worthing Priority Care and is responsible for mental health services across the county, accepted the report's findings and recommendations.

She said: "We have learnt the lessons arising from this review and have made substantial service changes.

"Health and social care in Worthing has undergone root-and-branch reform since Sarah's death."

Improvements included building a new mental health in-patient unit, better communication between agencies and the recruitment of more nurses.

Marjorie Wallace, chief executive of the mental health charity Sane, said: "We are shocked there has been no full independent inquiry about the circumstances leading to the death of Sarah Lawson.

"While finding serious failures in the psychiatric services and a dysfunctional mental health team, the panel also insinuate fault with the family.

"We question the validity of this costly report, which has taken four years to complete.

"We do not wish to promote a culture of blame for hard-pressed services but without a proper legal inquiry to reveal the true failures in the care and treatment which led to Sarah's tragic death, vital mistakes will continue to be made and more lives unnecessarily lost."