This Never Occurred To Them Before The Coroner Suggested It..?

'Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the trust and/or the police to be documented.'

For 'service user' read 'potentially dangerous mental patient'...

In his Prevention of Future Deaths report Mr Middleton wrote: 'During the course of that meeting the perpetrator disclosed that he was in possession of a knife, that he was sleeping rough and he needed the knife for his own protection.

'The members of the Dorset Forensic (Mental Health) Team did not probe as to where the perpetrator was sleeping.' He added the fact that he said he was carrying a knife was not probed further by the forensic social worker, who work with offenders with mental health problems.

It was also not recorded at the time in his records and not raised during a Care Programme Meeting - which monitors the package of care people with mental health problems receive - held the day following the disclosure.

Did anyone bother to do their job properly? 

Dorset HealthCare said they accepted the coroner's conclusion and will make changes to 'minimise the risk of such a tragedy happening again'.

Only 'minimise' it, because they clearly know they are employing people who aren't up to the job, and probably cvan't get rid of them... 

Detective Inspector Richard Dixey, of MCIT, said in 2017: 'Ryan died as a result of a brutal knife attack by someone he had classed as his friend.

'His death was tragic and needless and I hope the sentence handed down today will assist Ryan's friends and family in some small way as a step towards closure during what has been a terribly traumatic time.'

You don't think the revelation that it was completely avoidable adds to the trauma, then, Richard..?