I was just navigating the system on my own. No-one explained the risks to me. When it gets to crisis, it’s too late.
Mrs Calocane’s testimony is devastating to hear. But are we truly appreciating the cumulative effect of years of a loving mother trying to navigate an opaque, fragmented system? This is not simply one family’s tragedy. It is a warning about what happens when systems become process-driven rather than relationship-driven; when information is compartmentalised; when families are treated as peripheral rather than essential partners in care.
Mental illness at this level does not only affect the identified patient. It engulfs parents, siblings, neighbours, clinicians, communities, victims, and entire systems.
That is why this matters to all of us.
Patient safety is not just about policies, thresholds, documentation, or whether procedures were technically followed.
It is about whether people feel seen, heard, informed, supported, without judgement and able to act before crisis becomes catastrophe.
No mother should be left carrying fear alone while trying to interpret risk without guidance.
And no family should have to wait for a public inquiry to finally understand what happened behind the scenes.
Read part one of Mrs Calocane’s Testimony here
Last Updated on 1 June 2026 by MFCount2