The consultant psychiatrist who assessed Jack on the morning of Tuesday, 28 July, fully expected him to continue to improve. Whilst she was concerned that he might take drugs again, she thought that he had recovered from this psychotic episode.

However, she did not communicate to his family:

- first and foremost, the fact that she expected him now to be free from all psychotic symptoms;
- second, that any recurrence of these symptoms would be a cause for significant concern and potentially immediate action;
- thirdly, in exactly what circumstances professional help should be sought on an urgent basis and how to go about this.

Jack’s family were very worried indeed about his condition. However, because they had not been given the clinical expectation, they did not know that they could/should take him back to hospital, even though he had been discharged only hours before.

By the time they rang police that afternoon, Jack was on the point of leaving the house. However, they had felt something was wrong from the evening before. His brother had even trawled the internet looking for appropriate advice.