The Lorenzo Robinson case provoked questions about the treatment of the mentally-ill in Bermuda's prison system, which does not have a specialist psychiatric unit for the criminally insane. Here are the events leading up to, and following, his suicide in Westgate:

In 2000, 19-year-old Mr. Robinson 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 he stabbed Scott Jable in the back with a six-inch blade as the American visitor walked down Front 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".

However, 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. By 2005 no such unit had been set up and Mr. Robinson 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.

In March 2008, Mr. Robinson appealed to Chief Justice Richard Ground, who backed his plea for overseas help, branding the conditions at Westgate as unsuitable for his needs and at times disturbing. However, Mr. Robinson remained in custody until his death at the age of 28 in July 2008. He hanged himself using bedsheets in his cell.

Speaking after an inquest into his death last October, Mr. Robinson's mother, Dedona Grant, told The Royal Gazette his request to be moved overseas for treatment had been refused even after the Chief Justice's ruling.

"It was denied by Government. That's all I know. It p****s me off because it could have been done," she said at the time. "They could have the facilities (in Bermuda) but they don't have them."

Ms Grant said she was "shocked" that her son had access in his cell to the materials he used to kill himself making a noose from a sheet then wedging it into a ceiling groove using a battery which was an illegal item in the segregation unit.

After the inquest jury concluded that Mr. Robinson committed suicide, Coroner Khamisi Tokunbo announced he would file a report into the case for the relevant authorities, in the hope of preventing similar deaths in future.

However, he has now stated that he will not make his recommendations public, leaving the public in the dark over what has been done to address the underlying issues.