Lawyers Elizabeth Christopher and Llewellyn Peniston have called for an inquiry into the hanging death of Lorenzo Robinson at Westgate Correctional Facility. They are right to do so.

The facts of the Robinson case are these:

In 2000, he walked into Hamilton Police Station and handed explosives and bullets over to Police after smuggling them to Bermuda from the US. Although a social inquiry report found then that he was not mentally ill, Senior Magistrate Archibald Warner said: "But he is mad."

Mr. Robinson was later imprisoned and while in prison began to exhibit signs of paranoid schizophrenia, including hearing voices and inventing his own religion.

He was released from prison in October 2002 and within hours on Front Street, stabbed Scott Jable in the back with a six-inch blade as the American visitor walked down the street with his wife and child.

Mr. Robinson claimed to have acted after hearing the voice of Osama bin Laden, and was acquitted of attempted murder in October 2004 on the grounds that he was criminally insane.

That finding was based on the evidence of top UK psychiatrist Dr. Frank Kelly, who also recommended that he be confined in a "forensic psychiatric unit" in a hospital for the criminally insane.

He also said that keeping Mr. Robinson segregated in a locked cell would be "detrimental to his health".

But that appears to be exactly what happened.

Rather than being transferred to a secure hospital abroad, and with the then-St. Brendan's Hospital unequipped to care for him, an advisory committee appointed by then-Governor Sir John Vereker recommended that Mr. Robinson be remanded to Westgate, which was designated as "a hospital" for the purpose. He was also expected to receive occasional treatment at St. Brendan's (now the Mid-Atlantic Wellness Institute) while a secure psychiatric unit was developed at Westgate.

But by 2005, no such unit had been set up, and Mr. Robinson was actually moved out of the secure unit at Westgate where he had been held. He had also apparently stopped taking his medication, at which point he stabbed a prison officer with a sharpened toothbrush.

Prison officers protested, saying they had neither the training nor the facilities to supervise inmates like Mr. Robinson.

Two more years passed and Mr. Robinson himself appealed to Chief Justice Richard Ground, who backed his plea for overseas help in March, branding the conditions at Westgate as unsuitable for his needs and at times disturbing.

Such a move was apparently being worked on at the time of his death.

Obviously, it was too late.

Mr. Robinson is now dead. No one disputes that Mr. Robinson was a sick man who required specialised care.

Nor should anyone dispute that "the system" failed him, not just in his last incarceration leading to his death, but literally from the start.

Nonetheless, the negligence and failure of the prison system, the Government and Government House to provide him with suitable treatment and supervision since 2004 is a stain on this community.

Mr. Robinson needed help and he knew it. He was sane enough to ask for it, and he did not get it.

Only a full inquiry determining what went wrong, who was responsible and, most importantly, how such tragedies can be avoided in the future, will suffice now.