M ental I llness C oncerns A ll	It's a good job that the forensic history discovered in a penultimate forensic referral,compiled by a junior psychiatrist in forensic training, is not set out at the beginning of this Inquiry report, but is tacked on at the end, for the record is a long listing of preceding bad behaviour by Hardy, that seems to have been lost to mind, by those looking after the day to day management in his last psychiatric care, both in prison and in the psychiatric Unit. In the good old bad old days the junior admitting doctor would have made such a review, and a social history might have done the same. Hardy seems to have been estranged from his family. They declined to admit him when he arrived unannounced at their home. His early family days are not described. He arrives on an Order, forensic psychiatrists, examining him in prison, finding him suicidally depressed. Hardy was previously known to psychiatric care, diagnosed then as suffering from manic-depressive phases, but he had co-operated and had been well managed in that respect by regular supervison, and appropriate lithium medication, added to in this last year of care. Hardy was known to abuse alcohol, and this continued. He lived alone after a divorce. The divorce was followed by a long period of harrassment of his ex wife. That was not held in the front of thinking by those caring fro his mental health conditions. In the beginning of the last year leading to the tragedy, he followed up a grudge against a neighbour by damaging her flat . The police investigated, interviewd Hardy, and found the dead body of woman who was known by the police to be trading in sex for money, in his locked bedroom. There was evidence that Hardy was involved. Hardy denied all knowledge of this, explaining this down to 'blackout' associated with alcohol indulgence. At the following inquest on the death, postmortem examination revealed heart disease. That was accepted as the cause of death. Any part in the death, by Hardy was never sufficiently discovered, but everybody remained uncertain, but sure that there was more to be known about the death, and that Hardy had something to hide. Hardy was charged and found guilty of damage to the property of the neighbour and went to prison, from where he was transferred when he appeared to be depressed. Some months into his period of detention, the forensic examination was requested, but the forensic report, did not arrive till a month before the tragedy. It arrived too late to be of help to the hospital managers, who found him to be insufficiently ill as they saw him, compared with the grounds for his admission, to continue to be detained. Hardy had been represented at the hearing by a solicitor. Hardy went back to the flat. He kept in contact with a key worker until shortly before he was charged and found guilty of murdering two women in his flat. The Inquiry finds that the psychiatric team had dealt effectively with his manic depressive illness, which played no part in the tragedy. Although his alcoholism was never settled, it was not a crucial part of whatever led up to the killing. Nor could the Inquiry team see that the psychiatric team could have fitted a diagnosis of abnormal personality disorder to Hardy, on the observation and information they had about Hardy. There were aberrant personality traits, and insufficient attention was allowed to these compared to what was given to the psychiatric conditions - manic depession and alcoholism - so that the need for further delving into his conduct and history, was not pursued, and how he lived and his sexual history was not obtained. In this respect the Inquiry report offers an alternative risk assesment schedule, more sensitive to what was felt but never thoroughly aired. If he had been looked at from that point of view, the Inquiry accepted the advice of experts that there was nothing more than what the community team had done, which would have been different, or more effective. The Inquiry suggest that a risk assessment that took in mind the reservations that everybody felt about the part Hardy was likely to have played in the earlier death, rather than feeling they had to formally accept the verdict of the Inquest, then they would have been more likely to have gone back further and discovered the behavioural history obtained by the penultimate forensic report, at an earlier stage in his care Nevertheless it was not clear that secure detention could have been applied, But a referral to a multi-disciplinary assessment arrangement with probation [ MAPPA } After the final events everything becomes clear. Hardy goes to prison where he is re-classified as having an abnormal personality and can then be detained in secure NHS accomodation at Broadmoor. By then there have been ten forensic psychiatric opinions about Hardy. The local community and relatives of the victims, were outraged at the time, believing that 'psychiatry' shouild have done something other than letting their patient out and about, especially with the 'warning' of the earlier tragedy. The Inquiry report says those psychiatric mental health conditions which were present were properly treated. Serial killing is outside that remit. It is not written what investigation the police did following the finding of the body - the first death. That part of the local community which is the local sex trade held relevant information which was not addressed. back to Inquiry List The hospital Trust were quick to exhonerate them selves. It never sounds convincing.The usual offensive picture is published in the newspapers. 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