M ental I llness C oncerns A ll	BLOCKQUOTE>It may be that there was a coherent team practice when St was released from the special hospital but it became rapidly eroded by events Conditions that were laid upon St. gradually lapsed and were allowed to without any 'reining in' by the team by regular review and within the whole team to make decisive change and intervention. The fact that the key person originally was a probation officer, meant that ther could be no regular mental health service working practice with its consensus - no customary usage of experience together. The community mental health nurse arrived late as he was deteriorating. The consultant lead was unable to divest herself of the original lead - which she got because St. was released into the catchment area for which she then had admission beds - when she changed her work and left the adult mental health services so that there were no longer admission beds for observation and temporary holding care whilst something else was thought up. That shift of care responsibility was never resolved. The Home office left it to 'local arrangements - as they do. The local arrangements did not work - presumably the Home Office were told but did nothing, or the matter was just dropped locally. The nurse and the probation worker felt themselves uncertain and unsupported. They did not know how to complain. Or whom to call upon when their own options were insufficient. The route for this would have been their line management but although line management is what each sub-speciality wants there is little confidence that line management is prepared to be actively inquiring enough to supervise properly. They wait to be approached like the Home Office. Like the matron in Newby ( and later the worker victim in D.Joseph. ) the field workers are stranded. They were left making decisions when it was more correct that they realise realise they were out of their depth and should call in their rescue back-up. Where there are regular team meetings, or regular supervisory schedules, and it is no shame to bring things up because that is expected, then early changes in direction of what is being tried will be easier. St. had killed before and did so again. There had been no thought to a potential victim. Back to Inquiry Brown; Stoker	E-mail reaction is welcome mica@didgy.freeserve.co.uk