M ental I llness C oncerns A ll	His family background is not clearly known. When nineteen he was accused of a minor sexual offence with two young girls, following which he underwent psychological testing , which labelled him as subnormal, so that he was certified as a mental defective and detained for two years in a hospital for mental handicap. After that he regained regular work, finally as a surface worker at the local coalpit, married, established a family of two children and seemed to have settled down. The marriage ran into difficulties. RSt suffered a head injury which his then family said had changed his character. He became morose, neglected himself, and drank more heavily. He had never shown success in independent living . Short of money, he attempted to rob his mother-in-law. She became aware of what was happening and he killed her. Discovered to be illiterate and of low intelligence these were grounds for a diminished responsibility and he was sent to a special Hospital. In that institution he was not a problem and evdntually was considered to have been rehabiltated. The lead Responsible medical Officer who took on the supervision of his care after release ( because he was resettled in her catchment area ) was a specialist in adult psychiatry - not learning disability - and she lost her adult catchment facilities when she changed to a full-time psycho-geriatric commitment. She did however keep on some of her old patients and RSt was one of those. This proved unsatisfactory when he behaved badly because she had lost her adult admission facilities. She did then try to transfer his care to a colleague, invoking the help of the Home Ofice and her Health Authority in getting the tranfer, but was not succesful . The lead in social resettlement was a probation officer with no natural history of a working relationship with the psychiatric consultant . When RSt was first discharged , he was found a staffed hostel accomodation, for discharged mental hospital patients, run by the social services, and attended a sheltered work day centre . His living was structured and supported . Neither placement reached a settled routine . RSt started a liaison with a fellow resident - an ex-mental hospital patient . They pressed to be allowed to leave and were supplied by Local Authority social services with their own accomodation, with the intention of marrying . His behaviour at the work placement continued to be irregular and unsatisfactory . He drifted out of that and his liaison also petered out. His co-habitee returned to hospital. He was left on his own without any regularising habit to his weekly life. He drank more and more and showed increasing signs of self neglect . An adult service community mental health nurse was attached to his case and shared the supervision with the probation officer. A different residential hostel , expected to be the answer to his difficulties, refused to have him. He accepted a friendship with someone whom he had known in his first staffed hostel placement , but who now had her own flat which she looked after well. He said after the tragedy that she had brought up the matter of the previous offence. He killed her and was returned to the special hospital. Back to Inquiry List Home page Review Brown;Stoker Inquiry link page	E-mail reaction is welcome mica@didgy.freeserve.co.uk