M ental I llness C oncerns A ll	BR when aged 24 in February 1999 pushed a complete stranger from a station platform under an oncoming train, and followed him in its path. The victim was injured. BR was run over but unhurt. In June he pleaded guilty to attempted murder and was given a Mental Health Act Restricted Hospital Order; Section 37&41. He showed signs of mental illness in his first year at College, hearing things that were not said. He was referred by a General practitioner there to a Community Mental Health team, and was said to be better after four counselling sessions and stopping cannabis and ecstacy. A reference to matters following from childhood may have been to the divorce of his parents when he was thirteen. He failed his college exams and returned to live with his father, his mother being a little too frightened of him. After a mild physical confrontation with his father, he left the house and kicked several cars. Arrested at home, he was interviewed at a police station and revealed he was hearing disparaging voices, and felt the IRA were after him. He was therefore admitted to the local mental health admission ward and when discharged a depot regime had been started . When he complained of side effects medication was changed to sulpiride. He did not attend Care Pogramme Approach reviews. It was felt that at times he did not take the oral medication. He did attend Out-patient appointments with his mother. He failed to get in to the Army and held that against the local psychiatrist. Erratic behaviour with some fighting followed leading to his readmission to hospital on a Treatment Section 3 MHA 1983 Order. Depot medication gave recovery, but complaint of side effects again led to a change to oral medication. He then spent a long time on leave at home initially with a few incidents, but after release on a 'supervised discharge order' he had a steady six months spell. Social work was discontinued. A community nurse kept in contact although with little exchange with the family. Soon after the Order was extended Rathbone took a medication overdose which led to his hospital readmission on a Treatment Order. The Social Worker who best knew him indicated the following risk factors .. 1. poor compliance with medication 2. evidence of violence when unwell 3.a risk to himself 4. poor therapeutic relationship with the professionals 5. misuse of alcohol and drugs 6. continued denial of past and current illness so that he did not engage This third admission attachment of five months followed the pattern of the previous one - a depot restart, a Tribunal Appeal dismissed, assessment at a ward round without full consideration of Section 117 aftercare, Section 17 leave at home interrupted by brief return after incidents reported by his home, continued weekly depot injections, the last - a modest dose - on the day of the final tragedy. He was noted to be hostile on that day, so that, unusually, the ward checked out matters on the telephone with his father. Review	E-mail reaction is welcome mica@didgy.freeserve.co.uk