Details in the inquiry report make shocking reading.

Donovan Kitching had been jailed for six years and four months in September 2011 after pleading guilty to aggravated burglary and robbery.

In March the previous year, he and two other men had entered a house carrying knives and threatened a pregnant woman. Money was demanded and a number of items stolen.

Given the time he had already spent in prison, he was eligible for parole on July 6, 2013, the half way point of his sentence.

While in prison either on remand or serving his sentence, Mr Kitching was guilty of 33 adjudications against him for offences including assault, fighting, damaging property, abuse to staff and disobeying orders. He had 60 days added to his sentence.

Extraordinarily, he had attained enhanced prisoner status in September 2013, having been stripped of this earlier that year because of his conduct.

A social inquiry report in 2011 had assessed him as a high risk for re-offending and causing harm.

But probation reports in 2013 advised that parole should be granted subject to certain conditions and said he was now a moderate risk of re-offending although still a high risk of causing harm.

In December 2013, a month after he filed for parole, Kitching confronted a prison officer who said he felt under immediate danger of being assaulted.

But in March 2014 the parole committee recommended parole be granted, noting his major improvement in behaviour and that ’little would be gained from keeping him in prison’.

Mrs Valentine’s son Stuart said those words still ’haunt him’.

On April 1 that year, the DHA, under the power reserved to the Minister, ordered he be released on parole on certain conditions - including that he reside at his brother’s house in St John’s, take up employment and refrain from criminal conduct. He was released the following day.

But there was evidence that within days of release he was seen residing for a couple of days in Peel and then identified as staying at a hotel in Port Erin.

On the day of the tragedy, Mr Kitching had stayed up drinking until about 4.30am and admitted to have taken ’a little line’ of a Class B drug.

He got up at 12.50pm, persuaded the owner of a car to let him borrow it, despite never having held a valid driving licence or even taken a test and an eight year driving ban still being in force.

This behaviour was again a breach of condition justifying immediate recall and showed once more the total disregard Kitching had for authority and the law, notes the report.

The car was not roadworthy as the bumper was running against the tyre and the exhaust was lying on top of the rear axle.

Kitching drove around Douglas before heading up to the Mountain Road. At Windy Corner a witness saw the car being driven in a dangerous and reckless manner.

He was spotted at the Mountain Box by a police officer in an unmarked car who noted that the car braked hard to stop in time before a ’road closed’ sign and also noted that the wing mirrors and nearside wheel were damaged and the rear silencer hanging down.

The officer got out to speak to the driver but as he approached the car it drove away. He caught up with it at the Bungalow and caused it to stop.

A roadside breath test proved positive, so Kitching was arrested for driving while unfit. But then the offender asked to get his mobile from the car, prevented the officer from removing the ignition key and knocked him away before driving off at speed.

Kitching remembered going over a cattle grid and something happening to the car. The steering went heavy and as he took a corner the car snaked. He then saw some people ahead.

He remembered hitting a woman and then the car hit the verge and flipped. He got out of the car and fled the scene.

Three hours later he was spotted in Sulby and subsequently arrested and charged.

In October 2014 Kitching pleaded guilty to causing the death of Gwen Valentine by dangerous driving.

He was jailed for a total of 10 years and 72 days.

In his report, Mr Karran said: ’In my view parole should be earned and should not become an automatic right

’To award an extra three months of freedom on licence merely because it is close to the automatic release date is not a factor to be built in to these guidance rules.’

He said he was critical of the prison and probation service because practice had developed that led to insufficient investigation being made by officers tasked with making recommendations.

They were not given access to all prison records and the reports of other prison officers.

Clear conflicts in statements were not investigated and no formal risk assessment carried out for parole.

He said he could understand why the two probation officers made their recommendations but it was not made clear in their reports that these were only borderline recommendations.

But he said one of those probation officers, Lynda Watts, had stated if she had been able to read the whole of the contents of the dossier and had heard the evidence given at the Inquiry, before making her report, she would probably not have made the same recommendation.

Mr Karran said the parole application should have been deferred for clarification.

He made 26 recommendations including that a statement from the victims of the crime should be included in the dossier for a parole application.

Another recommendation - that police should be given power to detain a person who is found to have broken a parole licence condition or is suspected of so doing - has yet to be implemented.

Mr Valentine said police had this power in Canada.

DHA Minister Mr Malarkey said: ’We don’t want to make promises we can’t keep. This hasn’t been totally rejected. It’s something we are looking at.’