AbstractIt is generally accepted that those who suffer from mental illness are less responsible for their criminal actions than others. A fictitious case of a woman suffering from a paranoid psychosis, who severely injures her legal advisor, is considered in two different but related jurisdictions, England & Wales and Connecticut, USA. Four elements of the criminal process are considered. Significant differences between the jurisdictions are found in all four elements. There is greater pragmatism in the English system and a greater chance of the woman ending up in long‐term hospital care, but both systems aim to prevent further violence by the use of institutionalisation. International and intra‐national variations in the care of this hypothetical woman are briefly discussed, and it is clear that in both countries medical care is compromised by attitudinal and political considerations. Copyright © 2006 John Wiley & Sons, Ltd.