JUDGE Mark Brown has got it quite right in the case of Jonathan MacMillan.

A full inquiry is needed to understand the events leading up to this shocking attack in Barrow.

Far too often, patients are released long before they are fit to enter the community and the necessary support is in place.

No-one wants to see people detained longer than necessary, but if there is a risk of harm to themselves or others, then the hospital authorities have a duty to protect the public and keep the patient safe from themselves.

Over the years, this has happened far too many times.

Is it lack of beds, resources, expertise or purely a blunder, as it appears in this case? Whatever the reason, a family tragedy has occurred as a result.

If lay people can recognise that someone does not seem themselves, why can’t the professionals?

Or is the system so bogged-down by process and procedure that common sense goes out the window?

These are difficult judgements for those involved and the circumstances leading up to this need to be fully and openly explained and the chain of command accountable for their decisions.

Given how quickly the hierarchy of the health service closes rank, answers are needed as a matter of urgency.

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