In the circumstances it is my statutory duty to report t0 you: 1.The Police The evidence revealed that on the 6lh June 2013 the perpetrator made remarks to a member of the public to the effect that he "would not kill his mother" This information was passed to the Officers who attended the area. Some 2 hours later the same officers attended a call about a man behaving strangely and covered in blood: An ambulance was called The officers had not spoken to the original caller , who subsequently gave evidence that the remarks were that the perpetrator said he "would kill his mother" "Common sense told the officers that the person was one and the same and did welfare check on his mother. day they

At no stage did they question the perpetrator about his originally reported remarks. Also, citing confidentially they did not pass those remarks onto the Ambulance Team. This meant that when later seen by the psychiatric nurse the latter was in ignorance of this significant statement: It is possible that had the nurse been aware this may have altered the outcome of the perpetrator's initial assessment and how he was dealt with
2.The Partnership Trust The Coroner concluded that the evidence at the inquest showed that the perpetrator was suffering from a mental disorder when he tried to kill himself on the 6"h June 2013. Whilst the psychiatric nurse that day did not have all the information which was available at the inquest he had information to show that perpetrator had a history of self-harm, unemployment, family stressors, multiple and complex drug misuse, quasi-incestuous sexual feelings, past sex abuse, hopelessness, low mood and serious suicide attempt that
3.Not withstanding the above the nurse decided that the perpetrator was of zero risk and was not suffering from a mental disorder. He was discharged with the only potential follow up being talking therapy which would not commence, if it ever did, some weeks hence. The evidence at inquest shows that this was a disturbed young man having intended to kill himself 6 hours earlier and who remained a risk to himself. Whilst on the information known to the nurse at the time the tragic outcome could not have been anticipated, there was an opportunity to render care, which could, as a consequence have made a difference It is a concern that the two assessments after the killings also concluded the perpetrator was not suffering from a mental disorder.