M ental I llness C oncerns A ll	There is a long enough account of the illness to be sure C. suffered from schizophrenia, that help from depot injections was incomplete, and that use of the most potent oral medication for this condition - clozapine- produced a satisfactory suppression of obtrusive illness. He resists one admission until extreme force is exerted. He recovered sufficiently to develop employment in his own horticultural based business. What never happened was that he was succesful in independent living as well. A hostel placement did not offer a suitable cultural and companionship base. He returned to being dependent upon his mother. That dependent care situation got support, observation, intercession, and 'supervision' from his elder sister, who lived elsewhere. The temporary improvement, maintained by regular clozapine medication collected from his family doctor, complied with when in active contact with the professional services, lapsed, and became uncertain when he was probably not taking his medication regularly. He may have perceived his professional supervision to be less compelling. His contact with the mental health community service petered out, and the holding position was by out-patient review by a consultant relatively late in his care. The final consultant was not personally familiar with the florid original course of his care, nor had any personal knowledge of the degree of reliance that could be put on the reports of family observers in the display of illness symptoms, or aggressive behaviour. It is not clear whether he took part in regular team meetings from which he might have updated his information. These point examinations were not to show any significant illness. They were not backed up by any information from his day by day carer nor was his sister able to put in her reservations. His illness was manifest if intermittently, until it returned floridly and desperately, towards the end of one week. His sister conveyed the basis for her great concern and sense of urgency to the hospital Consultant, but it had to be done through the medium of the secretary to the Consultant, and the consequence was an appointment for after the weekend. Before that, the tragedy occurred. The sister seems not to have been told of other routes to contact - particularly how to speak directly to a member of the secondary community mental health services on duty - nor advised about the fall back summons to the family doctor - the family doctor surgery issues the medication and had taken the responsibility for regular blood testing - whose lead position in emergency, seems to have vanished. A previous partial and similar 'attack' had previously been taken - without conviction - as a joke. Reviewed	E-mail reaction is welcome mica@didgy.freeserve.co.uk