When Christopher Edwards was shown into his cell in Chelmsford prison in November 1994, he had little idea that his cell-mate, Richard Linford, had been previously diagnosed with schizophrenia and a personality disorder and was regarded by the police as 'very dangerous'.
Mr Edwards, who also had mental health problems, was killed by Mr Linford. His body was so badly beaten that he could be identified only from dental records.
The killing and the inquiry into it, conducted by a four-strong team headed by Kieran Coonan QC, had a huge effect on the criminal justice system in Essex.
The inquiry said Mr Edwards, who was on remand, should never have been in prison, let alone placed in the same cell as Mr Linford, who had already committed a series of assaults in and out of prison.
The tragedy is referred to in Essex simply as 'LinfordEdwards'. And since it took place, the county has developed a service comprising five criminal justice mental health teams, providing on-the-spot psychiatric reports for those awaiting trial. The teams make recommendations to magistrates on how offenders should be dealt with. They also follow up as offenders go through the system and when they finally leave it.
The teams also provide training for the police, probation services and magistrates.
South Essex Mental Health and Community Care trust, one of the bodies funding the mental health teams, says that thanks to the training, forensic professionals in Essex are among the best-trained in the country in mental health issues.
The Magistrates Association agrees: 'Training for magistrates can vary enormously, ' says Ann Flintham, communications manager. 'I am a magistrate in Hounslow and we haven't had any training in mental health. '
Essex magistrates' courts' training department arranges a training conference in mental health for the county's 700 magistrates every year. 'Training on mentally disordered offenders became compulsory for magistrates in Essex after Linford-Edwards, ' says David Tyler, training administration manager for the courts.
Presentations are given by academics, senior police officers and individuals from the criminal justice mental health teams. In the afternoon, delegates are divided into small teams and given scenarios to solve. 'It is difficult for magistrates to be aware of all the advice That is available to them, ' says Ken Stevens, a community psychiatric nurse on the southeast Essex criminal justice mental health team, who lectures at the magistrates' conferences.
'They do not necessarily know there are team members available to them in the courts. '
Without the training, magistrates might impose a custodial sentence because they are unaware of other, safe options, says Mr Stevens. 'They tend to think: 'If we give them a community sentence It is not going to work'. ' But on the contrary:
'Locking them up doesn't achieve anything if nothing is being done to treat the underlying condition'.
'This is a better service than most, ' says Naushad Nojeeb, locality trust manager. 'Most teams get people away from the criminal justice system, but they do not deal with the issues that lead people to commit offences.
'With this system they do an assessment and then provide a package of care to stop someone from committing another crime. '
The scheme also breaks down barriers. As Mr Stevens puts it: 'I have been very impressed with how open-minded most magistrates are. You tend to get this picture of middle class elderly ladies in twin sets. But they're not really like that. They have a considerable, growing awareness of mental health issues. '