The authors make some considerations on the situation in Italy five years after the closure of forensic psychiatric hospitals. The failure to adapt the penal code and the failure to strengthen mental health services have led to some critical issues. The custodial and treatment function of the old forensic psychiatric hospitals has been replaced by health service treatment pathways. In all regions, facilities (residences) for the execution of security measures (REMS) have been established, to which only patients who also need custody should be assigned. However, the opinions of judicial and medical experts often diverge: patients who could be treated externally are assigned to REMS or people who have no clinical indication for treatment are sent to REMS. There is a need to review the legal concepts of insanity and its relevance to offender responsibility as well as possible treatment pathways in and out of places of detention. The concept of social dangerousness is a matter for the judge; it is up to the clinician to describe the therapeutic possibilities in relation to the specific situation of the patient offender.