On 1st September 1993, Georgina Robinson, an occupational therapist working at the Edith Morgan Centre, was fatally wounded by a paranoid schizophrenic, Andrew Robinson, a patient detained under the Mental Health Act 1983. Andrew Robinson had been suffering from mental illness since 1978, when he was committed to Broadmoor Special Hospital on his conviction for possession of a firearm with intent to endanger a life. He is now back in Broadmoor, following his conviction in March 1994 for manslaughter on the grounds of diminished responsibility. The South Devon Healthcare Trust, which is responsible for the Edith Morgan Centre, set up a committee of three to enquire into the circumstances surrounding Georgina Robinson's death. Sir Louis Blom-Cooper QC, Helen Hally and Elaine Murphy uncovered a lengthy tale of ill-judged and misapplied care of a severely mentally ill young man by both management and those working in health care and social services.Quite apart from the failure of the Trust and its employees to observe the legal requirements for granting detained patients leave of absence from the hospital, the Committee discovered a general unwillingness on the part of the professional workers to listen to desperate pleas from Andrew's parents, friends and supporters as they recounted his successive mental breakdowns. The alarming conclusions of the committee are presented in this report. It should be of interest to those involved in mental health care and an increasingly concerned public.