M ental I llness C oncerns A ll	First clouded by assigning too much emphasis on street drugs and alcohol, over Xmas 1997 , when with his parents, following the failure of a five months period looking after himself in a flat, the diagnosis is subsequently accepted as that of schizophrenia. The illness responds to one of the new medications, and it seems he takes medication in the community when it is issued and supervised by the hospital. In a later phase he does not renew after one prescription from a family practitioner. The eventual community team and the family doctor are not in touch. The family keep in touch with him throughout, mainly through the mother, who works in the mental Hospital of the final admission period, which serves the second catchment area when he is discharged from the first catchment area to stay in his family home. The father, and sister nearby also on hand, are available to report in their observations of any change in behaviour and outlook. The sister is the first person to make known his defensive weapon use- putting a machete and knife under his pillow, and having them in his hand around the house, whilst on overnight leave with her.The sister reports this to the first admission hospital. They report the situation to a duty Social Worker, who is the eventual victim when she later becomes his keyworker after he is placed in a Local Authority hostel which accepts those getting better form a mental illness. The Social Worker does not see the family or AJ himself. She advises the matter go to the police who respond and he is readmitted from the Police station on an Order. He is well recorded, when ill, as believing organisations were after him, and that he was connected with God. He is known at times not to respond in interview with a full truthful account. Whilst an in-patient at the second hospital he is recorded as issuing a threat against the staff he met during his first hospital admission. He has neither job qualifications nor an experience of capable independent living.   After his first extended admission of three weeks he is going to give up his own flat in the catchment area from which he was first admitted and live in an adjacent catchment area with his parents. The transfer to aftercare in the new catchment area is left till after his discharge, to be introduced by the CPN from the first aftercare team. The transfer is to a CPN from the second catchment area after he was seen and accepted by the lead clinical psychiatrist. It is not clear that the whole team discusses the acceptance - which will mean that the social worker who becomes his final keyworker has no direct identification with him. He is subsequently readmitted to that local hospital and spends five months there as an informal patient being re-established on medication. Although in the locality of the family connection, there is not the same individual contact with the family - as carers. In the pre-discharge period his clinical lead in hospital is with two locum doctors, the final one being inexperienced for the post. There is poor assembly and recognition of the relevant material facts in the second catchment area. There is no adequate discharge Care Programme preparation, and no clarity as to who holds future charge of his case, the named person in the hostel to which he will be discharged , or the Approved Social Worker who, after he has been settled in the hostel, becomes designated the final linking keyworker of the community mental health team, He is resettled to a Local Authority Hostel in the catchment area, well established as accepting mentally ill patients for their aftercare rehabilitation. The key worker after final discharge from the local hospital begins as the team community mental health nurse for the locality. She is not aware that he has failed to renew his prescription from a family doctor. Medication is unsupervised at the hostel. Because the next step is going to be a move to self contained flat the nurse, without any prior discussion at the team meeting, hands over the key role to a team social worker. The social worker has had no personal contact with him ... [ but had previously received, whilst being the daily on-duty Approved social worker, the hearsay information that he possessed a machete and knife and was wandering around the house of his sister with these weapons, whilst on overnight leave from hospital ] .... or his circumstances and history, and has had no contact with his family, his family doctor, only indirect information of the situation inside the hostel, and little opportunity to receive direct supervision herself. Deterioration brings a decision to admit but uncertain aand changed arrangements on the day means the Social worker meets AJ. on her own, in the hostel. Things go wrong and she is stabbed many times with knives that he twice goes to collect from the kitchen. Reviewed	E-mail reaction is welcome mica@didgy.freeserve.co.uk