Rita Salmon killed her estranged husband
She is in mental health care may 27 – July 27 2002:.

This is a very late Inquiry. The panel chair is a retired general psychiatrist and lecturer.
There is no previous psychiatric history.

Family history is not raised.

Salmon is continuing a disagreeable break up with her husband who has left her for someone.
She considers this reflects in some way upon herself.
Salmon suffers from epilepsy.
Perhaps abuses alcohol sometimes.

She is in touch with her two chilldren, who moved in with her, at the time she was being assessed under the MHA.
Salmon had been seen and assessed by the Trust psychiatric services at the time of overdoses and self injury, those seemingly arising out of the uncertainty and upset associated with the departure of her husband into another relationship. Adjustment difficuklty in a time of transition was the labelling at the time
The Consultant, not the local catchment area one for Salmon, and an Approved Social Worker found no grounds for a Mental Health Act section admission. The family did not want that.

They later go on holiday with her to Turkey,
During that time abroad S makes another overdose in circumstances not explained by the family
who accompanied her.but the panel notes it required intensive care.

Risk assesments werepart of the ongoing contacts, but were not about risk to others but about risk to self
The Trust, providing mental health care on account of the self injuries and overdosages, has to deal with some adverse criticism after the Court verdict.

One from an independent doctor, who is quoted, ackowledging hindsight, as saying there were grounds for MHA sectioning – although Dr Mezey had never seen Salmon.

There was also in comment in the press interest, information not held or sought by the Trust service, about the degree of turbulence in the marriage before the break up, and about two incidents where Salmom attacked her husband's car and another occasion of aggression.
They did not get into any assessment of risk to others.

These were not known by the mental health team at the relevant time.

They would have been known to the family but the Inquiry makes no note of them ever having been approached to give observer information, nor a social history, nor any account . Say, of the overdose and behaviour leading up to that in Turkey, which they would have observed.



The family declined to attend this Inquiry The estranged husband is the victim.

It is not known whether they were offered any other form of entry into giving information to the Panel

Salmon is seen during two weeks by a community mental health nurse soon after the return from Turkey, and copies her view to the GP and maybe a supervisor, but the latter is not commented on or looked into by this Inquiry.

A first contact in the last three weeks is open and a preparation for further contact. The second is more relevant and not abnormal,
The final contact before the tragedy is curtailed by Salmon who is tearful and depressed.
The nurse is to go on holiday, so raises the issues at the routine weekly team meeting that occurs on the same day: and makes an arrangement for another team member to be available, but does not manage an introduction.
The tragedy occurs two days later, a day before the substitute visiting nurse was down to call.

There seeems to be no contact at this time with the family and no comment that any effort was made to do that.

As often in Inquiries of this sort, there is no information in this report about matters surrounding the incident, nor of any post Court diagnosis, nor of any follow up: or even about disposal

Comment Bradley; Salmon

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