M ental I llness C oncerns A ll	"T" experienced violence as a child, and it continued in her adult relationships.There was enough in her lifestyle to account for depression, but she often got the medication given for endogenous moods - that is phases of stuck and continuous mood change - not caused by outside events. Social work mostly concentrated on rehousing and re-equipping her with personal belongings and getting a fresh start. Neither the community mental health nurses nor the social workers got to grips with her layered family hinterland. Her care was reactive, often to non-dangerous overdose behaviour, a response usually to difficulties in her personal companionships. The Panel decides that the care given from a day centre was insufficiently active. It had lost its way. The centre had lost close contact with Social Services. They had left for different premises. Their Record systems had diverged. Service from psychiatrists had diminished and stopped. The centre became a base for community nurse only mental health teams. Their lead was carrying a big case load as well as management and organisation duties. The Panel thinks more could have been done by the team to seek out the close network of "T" and set her problems in context. The Panel felt lead psychiatrists had not used the Care Programme Approach (CPA) as a working practice - as something they used in the way they addressed patients. They often did not turn up to Reviews. "T" was classified at the lowest level. "T"and a current 'partner' sometimes quarrelled.Such altercations led to assaults. In the final one, after they had been out drinking, "T" stabbed and killed her partner. Reviewed	E-mail reaction is welcome mica@didgy.freeserve.co.uk