The family of the serial killer who butchered ticket seller Marie Harding battled for years to get his behaviour taken seriously.
Daniel Gonzalez's mother Lesley Savage was told time and again a "crisis" would have to occur before he could be sectioned and given the treatment she felt he needed.
In a chillingly prescient letter, Ms Savage once wrote to social services asking: "Does my son have to commit murder to get help?"
Gonzalez, 25, is today facing a lifetime behind bars after being convicted at the Old Bailey of murdering Brighton and Hove Albion worker Marie Harding, 73, to emulate his horror film hero Freddy Krueger. He was also found guilty of stabbing to death another man and a married couple in an orgy of violence stretching from Sussex to London in September 2004.
Gonzalez, who lived with his mother in Woking, Surrey, attacked at random, knifing Mrs Harding in the street near her home in Southwick and breaking into other victims' homes in London to carry out savage attacks. High on drink and drugs, he picked on the vulnerable and elderly and had hoped to get his murder tally into double figures. He had pleaded not guilty to murder on the grounds of diminished responsibility, insisting that voices inside his head had told him to kill.
But a jury took just one hour yesterday to find him guilty on all four counts.
Only months before his horrific killing spree, Gonzalez wrote to his doctor begging for intervention.
He said: "Please, please, help me, this is very urgent," he wrote, in a scrawled and frantic-sounding letter that he took personally to his GP.
"I really, really do need medical help to find the correct environment and the correct medication."
But his family say his situation was never quite desperate enough for the professionals who assessed him.
Two days before Gonzalez killed Mrs Harding his mother Lesley Savage rang the police begging for their intervention after he was seen running naked in the street.
She said: "Every time we asked for help for Daniel or Daniel did himself, we were told we would have to wait for a crisis to occur before he could get the help he needed. Whenever we thought the crisis was looming, it was never looming enough."
An independent inquiry has been opened into just how Gonzalez came to be free to kill four people.
Surrey and Borders Partnership NHS Trust treated Gonzalez for seven years from 1997 through its predecessor organisation, the North West Surrey Mental Health Partnership.
In March 2005, the family say they made a complaint to the trust about Gonzalez's care and treatment, alleging more than 100 instances of poor record keeping, poor communication between professionals and between professionals and the family.
They claimed there were examples of "baffling" contradictory diagnosis and treatment and even of letters being sent to the wrong addresses.
Daniel Gonzalez's problems had begun when he was 15, when he began to dabble with drugs and became introspective, struggled to concentrate in class and could not conform to a normal day-to-day routine.
Despite being highly intelligent, he suffered from dysgraphia, a writing disorder and had generally poor motor skills.
After leaving school, he flitted between college and various short-term jobs, but his drug use escalated he used cannabis, amphetamines and ketamine and he found himself in trouble with the law.
Eventually, aged 18, Gonzalez was admitted to a medium secure unit, where he was placed under close supervision and diagnosed as suffering from "continuous paranoid schizophrenia". In one incident at the clinic, he was discovered hitting himself over the head with a pan, saying: "Get out of my head".
After being discharged, Gonzalez went to live for a time with his family in Spain and when he came back, in late 1999, he seemed fine. His medication, an old-style psychiatric injection, seemed to improve his condition and he even had a girlfriend, although he was unable to hold down a job.
But Gonzalez soon became tired of the drug's debilitating side effects the dribbling, the constant shuffling and the muscle spasms and asked for a different treatment. However, his family say he was refused a new medicine because he was still taking cannabis. After being convicted of robbery in 2001 he was sent to a young offenders institution. While in custody, Gonzalez was assessed by a psychiatrist who, the family claim, concluded that he was not seriously medically ill and suggested that the voices he claimed to hear could be due to his "disassociate state".
After his release, Ms Savage tried in vain to convince a series of health professionals that her son was seriously mentally ill. His family estimate that he saw as many as 15 different psychiatrists.
Ms Savage claims to have encountered arrogance and was usually ignored. One doctor even allegedly said that her son had a history of fabricating his illness.
But she was convinced of the seriousness of his condition. She explained how he could "keep it going" for half an hour long enough to fool the psychiatrists.
"They (the doctors) did not believe us," she said. "Some seemed well without medication' and I would say 'Are you telling me my son is not ill?'."
The mental health charity Rethink believes Gonzalez's case does not represent a failure by medical professionals to talk to each other or to involve his family.
Paul Corry, director of campaigns, said "Each time there is an inquiry (into these types of cases) they find the same thing, professionals not talking to each other, poor record keeping and the family not being listened to."
Surrey and Borders Partnership NHS Trust said yesterday there was no direct link between his illness and the "shocking attacks". Gonzalez had shown "no sign" of serious violence towards others.
A spokesman said: "Everyone who was involved in his care was shocked and horrified to hear that he had been charged with these dreadful offences.
"The trust offers its sincere sympathy to the families of Mr Gonzalez's victims."
Gonzalez received "extensive help" from mental health professionals at the trust.
However, because he was a drug user and admitted feigning illness, it was "very difficult" to diagnose him precisely, it said.
Fiona Edwards, the trust's chief executive, said: "Mr Gonzalez was a disturbed young man who acted as he did from forces that we may never fully understand."
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