The MWC report identifies weaknesses in the management of risk by the professionals providing care and supervision to the patient, notably that basic risk assessment and management was not in place. The consequence of this and other governance and management failings was that when the patient relapsed appropriate action was not taken. Traditionally the care of individual patients has been the responsibility of individual professionals and the Mental Welfare Commission report correctly identifies flaws in this approach. The systems of clinical governance and the requirements of the Memorandum of Procedure on Restricted Patients were ineffective in addressing these deficiencies.