M ental I llness C oncerns A ll	This Inquiry Report is forthright and full, clear and relevant. There are many omissions in mental health practice in this catchment delivery system. The catchment hospital was not fit for its purpose. Acute observation was impossible because of overcrowding and a high percentage of MHAct admissions on Section, and in a context of neighbourhood drug use climate. Coherence and leadership as a working team seems to have been lost. Review and needs assessment plans therefore could not be implemented.The clinical lead, felt abandoned by the local provision, left since for private practice. He called an aftercare review CPA after WH absconded. Nobody turned up. There was no real risk assessment, and little attempt to seek information 'in-between' from other family members - the mother might have been defensive, but a sister knew about his behaviour,and later was forthcoming. As in many other Inquiries - child protection and other tragedies - there is information which neighbours, relatives, other agencies have, which is not sought and does not get into the decision making professional circuit. The Inquiry Panel notes that Approved Social Workers, putting into effect MHACT Orders, no longer have to bring in a family and social circumstance report. When was this implemented? That natural opportunity for keeping a family contact route no longer exists. The Inquiry was taking interviews in 1997, so what were the problems that led to it being released for publication in November 2001. We are not seen as fit to be told why but it is said in the introduction that WH. did not give early assent to his records being examined. At the final stage he was in police hands in the middle of his shooting spree, which they had not heard about, but was not detained as he was not connected with the first tragedy. Further wounding and a killing occurred over the next days. They do not seem to have been aware that he was on bail from the original gun possession offence, and that he had therefore been in breach of that, and could have been detained. The detective in the first police arrest - for having a gun - opposed bail at that time on grounds of potential risk. He, at least, will be satisfied with his work. He did not know that there was uncertain hospital supervision subsequently, or that other police stations were finally involved with immediate investigation of the assaults. It's an old incident but with up to date resonance. Inquiry Coonan; Hutchinson	E-mail reaction is welcome mica@didgy.freeserve.co.uk