Where was the duty of care to Ken Goward and Roger Lamb on that hospital ward - and equally where was the duty of care to Harry Bosomworth, whose mental health needs should have been met to keep him safe and to protect fellow patients and staff on the ward.
Why was a patient who had been treated for paranoid schizophrenia since 1980 taken off his anti-psychotic drug - surely his medical background was known and failing that his family should have been listened to.
Mr Bosomworth had earlier been abusive to staff and security staff had had to be called. Why then was he left on the ward alone, where he later set about fellow patients with his walking stick.
Why did it take over a year for this hospital report to be made. It has only surfaced now because it has been leaked.
Yesterday’s YEP investigations discovered the report was completed in March 2016, but because it found a number of failings NHS England said it would carry out their own inquiry into the incident.
Inquests on the deaths of Mr Goward and Mr Lamb were opened in 2015 - those families are still waiting for answers, the inquests cannot resume until NHS England has completed its investigation. It should not take this long.
This newspaper has campaigned for over a year now for greater understanding of mental health through our #Speakyourmind campaign.
It is frustrating to see a “low level of basic knowledge” by acute medical staff of the needs of people with comorbid mental health issues, being reported. Whist we are glad the Trust has made changes for the better, a two year wait for a full report does not fill anyone with confidence that it won’t happen again.