M ental I llness C oncerns A ll	She has an uncompleted childhood. She develops tension and panic, said to be relieved by slashing her forearms and later her legs. She abuses medication drugs taking innumerable overdosages. C. has on record that she has tied up a man and cut him. That becomes obscured.A Unit at the Maudsley dedicated to understanding and helping out such behaviour, does not achieve a solution, but remains a source of expert advice. Almost by definition for a person with a personality disorder, unruly things happen around her. A nurse in the Unit moves into a closer relationship, either before or after her in-patient stay at the Unit. A carpet is drawn over the episode and they leave together for Somerset, followed by an incomplete discharge description of what was going on. Because the male nurse who accompanied her in some sort of relationship is working in the catchment area where they are living together, a neighbouring catchment area stand-in appointment is made with the lead clinician there. He recognises the likelihood of long-term trouble coming, knows the limitations of the leadership he can offer, in the circumstances that the three core elements in the mental health community are not together in a working team, and looks for a temporarising, holding and supportive but distancing arrangement, until the local domicile situation and the damaged relationships of these two becomes clear , and until a more steady and sturdy holding structure can be prepared for what might follow. She is referred to be seen for 'psycho-therapy' by a part-time ex-colleague, outside the local NHS health community.That referee has no success to report, distances herself, declares that there will be future difficulties, which should dealt with within a fresh future assignment with local resources. but without achieving a definitive referral back to a clinical lead. The recipient is now in a different catchment area. Her previous contact with mental problem help service is a referral, from the local casualty department which has to deal with her numerous overdose and selfharm attendances, to a delegated two man service from the Local Authority Social Work department, which accepts such referrals and tries to do something with the repeat attenders. They are relatively unsupervised and not connected to mental Health provision. A new family doctor refers her to the local mental health community 'team', and a nurse in a corridor is given the referral, and sees her thereafter without benefit of supervision, which the team clinical lead in any case says the nurse team members would not accept. No leadership emerges which draws together a care plan. As she is in only one service support type, the Health Trust advice is to make that the least grade of CPA. . She discloses that the male nurse who has moved to Somerset with her, may well be misusing his position at a hostel in the neighbouring catchment mental health area services. A senior Health manager advises caution and delicacy in using the information - which has been given within a clinical relationship, and which therefore cannot be openly attributed, if the informant demurs , which she does. The local manager at the centre where the male nurse works looks informally into the allegations and cannot substantiate any. C has made allegations which are not accepted. That kind of rejection, kindles the flame of resentment. The Inquiry Report is adversely critical of the way this possible breach of discipline by a nurse, is handled, and similarly condemns the attitude of the Maudsley Hospital managers, who never formally looked into what may have happened whilst the male nurse worked there, never resolved his conduct, and were difficult to the point of obstruction when asked for information by the Somerset Trust. Somehow in her contact with the Health facilities, she has met and got herself a fiancee who is a fellow patient. It is him she kills. The circumstances of what led to that relationship and to the final event are not described at all. The Report does not clarify the position of the male nurse whom she accused of misconduct, and with whom she continued some kind of out of working hours entanglement, but does adversely criticise the economy with which the Maudsley hospital gave a reference for the nurse. Neither the particularity of clinical handling at the Maudsley, nor her therapeutic journey with the Somerset Services are made at all clear. It is difficult to see in this Report any coherent account of a story unfolding. The presence of a personality disorder unhinges orderly account - in the Report also, it seems. Review.	E-mail reaction is welcome mica@didgy.freeserve.co.uk