On sentencing Jason Mitchell to three terms of life imprisonment for the manslaughter in December 1994 of three people - first a retired couple and subsequently his father, whose body he dismembered - the judge at Ipswich Crown Court on 5 July 1995 expressed the view that it was difficult to understand why Jason, a restricted patient, had been allowed back into the community Were the doctors at fault in their diagnosis of Jason's psychotic symptoms? Were they wrong in thinking that he was fit to return to the community so soon after becoming mentally ill and being hospitalized in 1990? Did the Mental Health Review Tribunals in 1991 and 1993, which sanctioned Jason's conditional discharge, act in error? What happened to Jason's prison medical records of 1988-9, which disclosed signs of oncoming schizophrenia while he was serving a sentence of two years' youth custody? Were doctors, probation officers and social workers handicapped by the absence of these records? These and other pertinent questions relating to the management of Jason's case by mental health services, and the care and treatment he received from doctors and nurses, are fully explored in this report of the independent panel of inquiry set up in 1995 by Suffolk Health Authority.