M I C A	Marden had two brothers: an elder one of whom certainly suffered from schizophrenia, at home when not in hospital care, or living with a cousin, the grown up son of G 's sister; the other ill brother in Ireland, labelled as disabled by severe neurosis. Marden never found regular self supprting work, nor independent living, nor a satisfactory companionship. He had declared a bisexual stance His main contact was his parents, and their continuous support was from a nearby married sister. It was accepted that the parents knew the professional mental health system because they were in contact with that during the illness of the other brother. The first diagnosis of illness was at a hospital in another area. It was a hospital admission and the diagnosis was of schizophrenia, though there had been some street drug misuse. In hospital he had at times been violently disturbed, once attempting to jump through a window, head first. He was discharged on an appropriate medication for schizophrenia, but did not keep this up when the family moved and he followed into to the area where the final event occurred, two years later. Marden ( Greg ) was seen by a consultant psychiatrist at Out-patients, the referral there coming three months after the family doctor had considered a consultation with him about aids and uncertain sexula orientation , to be more of a misbelief. Greg always resisted comparison with his brother. The psychiatrist wrote that G. was in the realms of paranoid reaction, maybe paranoid schizophrenia, which would maybe be provoked by street drug misuse, presently not active even though off medication but that at the interview G. seemed reaonably with capacity and could be left to be seen in three months time. G. did not keep that appointment.There was no referral to the community mental health team. Information from the brother who had schizophrenia was that G. was alright. It was left to the family or G. to initiate any future contact with the secondary service. This never happened It is likely G. was never subsequently on medication The mother and married sister left for a holiday leaving G. to look after his father who had asthma. After two days of heightened ill behaviour, G attacked his father. He died three weeks later. At some point he had accused his father of child abuse - but when later somewhat recovered and settled said that was a misbelief. It took some time for the clinical and adminstrative staff at the provider Trust to recognise that this incident required a serious incident Inquiry. That was conducted by someone without the experience, or the call on command, to do one properly Comment Holwill; Marden

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