The heartbroken children of two respected academics killed by their son while he was in the grip of acute psychosis say their mother used to wonder if it would take something shocking to happen before her son got help.
Alexander Soares and Katherine Weston said yesterday that the family had been shunned at every turn by the WA mental health system.
They said that at the height of their mother's frustration, she would ask whether she needed to jump off a bridge to get people to listen.
But nobody in the family had imagined the chilling tragedy which awaited them.
After years of battling to get Nicolau Soares the treatment he needed for the symptoms of his schizophrenia, Dr Weston and her husband Gavin Mooney died at his hands at their isolated Mountain River property in Tasmania on December 18, 2012.
Speaking to _The Weekend West _ a day after a Hobart jury unanimously found Mr Soares not guilty of double murder on the grounds of insanity, his siblings said alarm bells should have been ringing in the months leading up to the deaths.
But they said inadequate systems, failed communication and a lack of consultation with their family culminated in the tragedy.
"This was foreseeable, there were too many warning signs," Ms Weston said.
Echoing the frustration of their mother before her death, Mr Soares and Ms Weston said their brother had become increasingly affected by delusions and paranoia and was twice evicted from his accommodation in Fremantle in the weeks before his move to Tasmania.
But the warning signs were not reported by the accommodation provider to his outpatient care team at the Alma Street clinic.
They said Mr Soares had failed to keep a medical appointment and get a prescription for his antipsychotic medication but his family were not informed.
The siblings said despite the family's formal request for Mr Soares' medical care to be transferred to Tasmania the day before he left WA, no action was taken by staff at the clinic to link him to a service in Tasmania.
Then, when a crisis arose, the clinic claimed it was unable to take any action because he was outside WA.
A Health Department spokeswoman said there had been a telephone call and two home visits in an attempt to contact Mr Soares after he failed to attend a medical appointment.
She said Mr Soares was living in independent accommodation and there had been no responsibility for it to communicate with the Alma Street clinic about his behaviour.
Health services were not aware of his relocation to Tasmania until he had already moved.
She said the involvement of parents and carers in treatment was being strengthened since the Stokes report into the mental health system.