NEWS FOCUS: When the mental health service failed Gilbert Kopernik-Steckel, it cost both him and his mother their lives.Paul Smith talked to Gilbert's sister about the lessons to be learned

The life of Christina KopernikSteckel was ripped apart in 1996 - an innocent victim of incompetence within Britain's mental health service In January of that year, at their home in Croydon, she witnessed her brother Gilbert - a 33-yearold architect - take a knife from the kitchen and stab their mother to death.

He then committed suicide by slashing his own throat.

He was mentally ill, suffering what was later described as a 'psychotic episode'. He should have been cared for, but during the subsequent inquiry into the tragic events it became clear that this had not been the case.

Failures of communication, procedures and professional practice at the then Bethlem and Maudsley trust (now South London and Maudsley trust) meant not only that he took his own life and that of his mother, but also effectively destroyed that of his sister. Christina suffered post-traumatic stress disorder following the attack and a host of other psychiatric illnesses.

Unable to work, she was awarded more than£500,000 in an out of court settlement with the trust this month.

It is the first case to meet the criteria needed to claim negligence against a hospital for the actions of a third party.

But for Christina, who had just graduated from Oxford University at the time of the tragedy, its importance is that it has once again highlighted the flaws in Britain's mental health service.This tragedy, like so many others before it, was probably preventable.

On Friday 12 January - two days before the killing - Gilbert's behaviour became erratic.

He broke windows, ripped a door from its hinges and appeared to be suffering extreme paranoia that included making threats against his mother.

The police were called and later that afternoon he was examined by a GP and a consultant psychiatrist.

At this point, Gilbert should have been 'sectioned' under the Mental Health Act, but although the seriousness of the situation was recognised and the forms completed, they were not passed on to the social worker who could have carried out the procedure.

Twice over the next two days, Gilbert voluntarily admitted himself to a secure mental unit and twice he fled. Despite the desperate concerns of his family, and of Gilbert himself, none of the staff stopped him.

The second time proved fatal.

While hospital doctors were discussing ways in which he could be sectioned, he ran from the hospital and caught a bus home. The police were alerted but they arrived too late. Gilbert and his mother were already dead.

Today, Christina lives in the Netherlands - in part because she does not want to be treated by the system that let her family down so badly. But she wants to talk about her experiences and highlight the urgent need for reform and investment in Britain's mental health services.

'I think we were aware of the problems facing mentally ill people in getting care and treatment before it all happened, but it is not until you get caught up in it yourself that you realise how bad it can be. I do not have any real anger at what happened. It is a destructive emotion. I know that the staff who were responsible for looking after Gilbert are not bad people.

'But you are in this situation where you are so concerned, so worried about your brother and they just do not talk to you; they do not tell you what's happening. It seemed that when Gilbert was actually in hospital it was chaos.

There were not enough staff around, there was no-one to speak to and it was just a horrible environment. In a way it wasn't surprising that Gilbert ran away both times. A reception area seemed bright and new, seemed as though it had money spent on it, but the ward itself was appalling.'

Christina's criticisms centre on the government: its unwillingness to make the necessary investment in mental health services and its slowness in bringing in the promised reform of the 1983 Mental Health Act.

'How can we have a situation when they close down these hospitals in the early 1990s without providing real care in the community? It is 10 years since that happened and we still do not have a new mental health act and it looks even now as though we are going to have to wait until 2004 before It is made law. I think the government is being negligent.'

She describes Gilbert as her idol - the older brother she loved and looked up to. 'He was clever and charming; he spoke three languages. I adored him.'

And along with her mother, it was the main reason why she took on South London and Maudsley trust.

'It was about making sure they were not forgotten. I suppose I wanted someone to acknowledge what happened to my family.'

The legal process was hard.

Christina speaks of the enormous struggle of someone with mental health problems dealing with the law.

She had to undergo a series of assessments to prove she was ill.

But she is glad she succeeded. In spite of the doubts, she says she would never have coped if she had done nothing.

Speaking of the settlement, she said: 'It was just a relief. I thought: 'Yes, they actually believe me that I am ill'. That was so important.' l