On 21 October 1994, a senior social worker from Islington council in north London wrote to Mary Collins, replying to her worries about her 28-year-old son, Martin Mursell, a paranoid schizophrenic who was living in an uninhabitable council flat and was refusing to see her.
"We are unable to allocate a social worker because Martin does not wish to work with me, as you are probably aware. We will of course provide appropriate services if there is a further crisis," the letter stated.
Seven days later Mursell stabbed to death his step-father and almost killed his mother, in a frenzied knife attack. Three months earlier, he had been discharged from Whittington psychiatric hospital in north London, against his will.
Despite the worries of a housing officer that he would not be able to cope, he was placed in bed and breakfast accommodation and then into a flat which had no furniture, no gas or electricity and no cooking facilities. He received support despite his mother's pleas.
And on 28 October, the day after he finally agreed to his mother's request and returned to live with her and his step- father, Joe Collins, he attacked them both, killing Mr Collins and leaving his mother for dead. Then he gave himself up.
The tragic story of Mursell's mental illness reveals a scandalous lack of co-ordination and care and cycle of neglect.
His breakdown began in about 1985 when he began to have paranoid delusions. He was jailed for four months in 1988 after an attack on his girlfriend, and was first compulsorily admitted to a psychiatric hospital for three months in February 1989 when he was diagnosed as suffering from a schizophrenic illness. He was re-admitted for three months in February 1990. At this time he was living with his mother who found his behaviour increasingly threatening and violent.
In September 1992, the social services department went on strike and Mursell was not allocated a temporary social worker due to staff shortages. His condition deteriorated after he again stopped taking his medication and began abusing alcohol and other drugs.
Mursell's relationship with his mother was breaking down and he was allocated a council flat. But in January 1993, he had a violent psychotic episode, went berserk, and wrecked his flat. He was admitted to hospital again, under the Mental Health Act, and discharged on leave on the Easter weekend. He moved back to his mother's one-bedroom flat. At first he took his medication, but stopped after developing severe side-affects.
By October 1993, when his mother remarried, Mursell had deteriorated. After "squatting" for a while in his step-father's flat he was persuaded to sign away his tenancy rights and declare himself homeless so he could be placed in bed and breakfast accommodation.
In a letter written in May 1994, Becky Boyton, a mental health court worker, asked successfully for a charge of taking a car without consent to be dropped. "His recent history catalogues a total failure on the part of health and social services to adequately support him, despite continued effort on the part of his mother who has borne the brunt of the responsibility for his care and indeed treatment," she wrote.
She added: "Should another hospital admission become necessary, I can only hope that something has been learnt from the catalogue of failure over the past year and that better discharge planning will occur as a result." But her final, prophetic warning was ignored.
In July 1994, Mursell referred himself voluntarily to the Whittington hospital. But after only two weeks he was told he had to leave. The doctors said they could not see any psychosis and despite pleas from Mr and Mrs Collins to keep him in, he was discharged again.
After visiting his mother once in August he became aggressive and abusive to her. She called the social services department, to warn that she was worried about him, but the social worker's response suggests staff had given up trying to help.
On 27 October, Mursell moved in again with his mother. The next night he attacked her and his step-father. A bitter Mrs Collins said: "What happened on 28 October was avoidable if only they had listened to me. I told them all he was unwell and needed support - the doctors, the social worker, the housing manager. If they had done their job and acted when they were warned, Martin would have been in hospital, Joe would still be alive and my life and Martin's life would not be wrecked."