Picture this: I read the overnight incident log and it contains a horrible murder of a vulnerable person in the community. My first thought is for his immediate family and friends. My second is to see if there was any chance of preventing it. If so, what can we learn? Most serious case reviews show that a lack of cross-agency information sharing and timely decision making directly contributes to these sad outcomes. Looking at this case as part of the serious crime review process revealed similar issues.