Flawed procedures rather than the mistakes of individuals were to blame for the decision to release a prisoner on parole three months early - only for him to knock down and kill a walker.

A damning report into the parole system was published yesterday (Monday), more than three years after Gwen Valentine died on the Tholt-y-Will Road when she was a struck by an unroadworthy car driven by repeat offender Donovan Kitching.

Mrs Valentine’s son Stuart, who was walking with his mother and her fiance when she was killed on April 26, 2014, said the report showed Kitching’s ’24 hours of madness’ that led to the tragedy need not have occurred.

At a press conference, he told reporters that he had been profoundly shocked by some of the details that emerged during the public inquiry.

And in a prepared statement, he said he had been through ’three years of hell’ with no respite.

He said: ’This was 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. But that does not make this in any way acceptable. Collective, multi-agency failures like this tend to be worse as a result.’

He said the tragedy had taken place within a month of coming to the island to get a job here. He himself had been missed by Donovan’s car by only 1 or 2ft.

But he praised the response of the authorities. ’We’ve seen the best and worst of the island. I’m not aware of a response to a tragedy that’s been any better.’

’I don’t see eye to eye with everything. The response isn’t perfect but it’s very, very good.’

Inquiry chairman Geoff Karran concluded that based on the information provided, the then Home Affairs Minister Juan Watterson had made the correct decision to grant parole.

He said : ’I do not consider that any person broke any law, rule or regulation in connection with the release of Mr Kitching on parole. Basically, everyone followed the practice that had evolved.’

Mr Karran said the inquiry was a major opportunity to create a ’fair, reasonable and fit for purpose parole system’.

Mr Watterson, who is now Speaker of the House of Keys, said: ’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 DHA Minister, balances justice, rehabilitation and accountability.’

The DHA says significant progress has been made towards addressing most of the 26 main recommendations.

Procedures have been strengthened to deal with the recall of offenders who breach their parole conditions. Work is also continuing with the aim of giving victims of crime a bigger voice in the justice system, including the parole process.

Current Home Affairs Minister Bill Malarkey MHK said: ’We have taken on board the recommendations arising from the public inquiry. We are making positive changes in many areas and will publish annual updates on our progress.’

Bob McColm, head of the prison and probation service, said: ’Improvements have already been introduced and when the final elements are put in place, offenders in the Isle of Man will be more robustly managed than ever before.’

The report endorses the view that early release from prison on parole is a privilege that must be earned.

Unlike the UK where prisoners are granted automatic release after serving half their sentence, parole here is at the discretion of the Minister.

But if he hadn’t have been released on parole, Kitching would have been released automatically three months later anyway after serving two thirds of his sentence.

But Mr Valentine questioned what the public interest was in releasing someone who is still a danger to the public. ’We need to be clear about the risks we are balancing here.’

Clare Faulds, chairman of the Parole Committee, pointed out that Kitching was not a convicted killer when he was released on parole. ’Unfortunately, none of us has a crystal ball.’

Since 2011, the Parole Committee has considered 83 applications, of which 59 have been approved, 16 have been refused and eight deferred. Offenders have been recalled in 13 cases.