The tragic death of Denis Finnegan last September is evidence, once again, of the failure of community-based mental health services to respond to an emerging crisis.
As a Home Office conditionally discharged patient, John Barrett should have been seen once every four weeks by a psychiatrist. Yet, for the 11 weeks before Mr Finnegan's death, he was only ever seen by a social worker. The Home Office should have been kept informed of that lapse because his family had communicated concerns about his deteriorating mental state and he should have been recalled to hospital without delay. There needs to be a fully independent inquiry into the management of his care.
These failures to act swiftly are common. We are well used to them at the Zito Trust, having advised and supported bereaved families for more than 10 years. One of the common themes is the refusal of mental health services to recognise that families are often in the best position to know when it is necessary to raise the alarm. Many lives would have been saved had these early warning signs been taken seriously. Instead, our mental health services operate within a culture that underestimates the real risk some patients pose to themselves or others when they fail to follow prescribed treatment plans in community settings.
The Government is set on reforming mental health policy and law. Many new initiatives have been implemented over the years, yet the loss of life continues. It is now widely accepted that services are seriously underfunded and the need for significant additional resources is urgent. We also need to accept there are a number of patients who need to be monitored more closely, as they are the people who are most at risk of harming themselves or other people.
The fact that there are not enough hospital beds to cope with the demand means there are potentially dangerous people in the community who just shouldn't be there. Until we learn to accept that is the case, and that the families know who they are, there is little prospect of preventing these dreadful and unnecessary tragedies.
Michael Howlett is director of the Zito Trust which was set up by Jayne Zito to campaign for reform after her husband was killed