M ental I llness C oncerns A ll	Inquiry Mackay; 'P' extracted The remit of any inquiry is not about apportioning blame but should be an opportunity to obtain a truthful version of events which covers what was or was not done, and whether there was a possibility that the incident could have been prevented. It is also an opportunity to state good practice. The main outcome must be to increase public confidence and to promote professional competence. P attended several primary and secondary schools where he said he was bullied. When he left school he held a variety of manual jobs in the building trade and on the fishing boats but in latter years was unemployed. He moved to live in the Saltash and Torpoint area of Cornwall, returning to live in Plymouth when he was about 28 years old. He used drugs for some years, latterly regularly using amphetamine, which, he told us, he injected intravenously. P's General Practitioner (GP) first treated him for a mental illness in 1993 when he complained of suicidal thoughts and depression. In 1994, aged 26 years old, he was referred to a Community Psychiatric Nurse (CPN). In 1996 a Consultant Psychiatrist of Cornwall Healthcare NHS Trust, saw him and described him as "this rather strange young man with primarily panic attacks". a psychometric assessment demonstrated he was of low intelligence, although some of the tests he undertook were dependent on a certain level of social understanding and education, which he lacked In April 1998 P was admitted to the Glenbourne Unit Derriford Hospital in the care of a Consultant Psychiatrist, under Section 2 Mental Health Act 1983 (MHAct Observation order - 28 days detention ) from Charles Cross Police Station. P stated that he had recently 'broken up' with his girlfriend, with whom he had a daughter, after almost ten years. From the period of September 1999, until November 2001, P's care and treatment was irregular and disjointed with a number of organisations and personnel involved in his ongoing care and management, including Health, Social Services and Probation. The result of this amongst other things included P not receiving the medication intervention, he required to support his Mental Health care In November 2001 P's CPN wrote to his Consultant and informed him he had not seen him since August 2001. Between this period and May 2002 there was limited effort on the part of health and social care services to engage with P, despite some professional concerns about his behaviour and lack of contact with services. In May 2002 P was arrested for the murder of Mr. Warnes, a tenant living in the same rented house. changes in the delivery of community mental health services followed a 'reconfiguration' of the service in 1998 which changed ways of working from one large generic team to smaller specialist teams and had implications for primary care provision as well as secondary care services. longstanding managerial issues had major implications for the well-being and performance of the staff of the Waterfront PCLT. The issues included alleged poor staffing ratios, onerous workload upon some individuals caused by constant staff sickness, poor record keeping and staff mistrust of change and their managers Found that- The death of Mr Warnes could not have been predicted but may have been prevented if more assertive action had been taken by the mental health professionals responsible for his care. P was mentally unwell at the time of the incident. There were lost opportunities for passing on detailed information about P's previous mental health history and convictions. The Consultant Psychiatrist should have adopted a more rigorous approach in managing P's care once he was released from prison and living in the community. The CPN had a poor understanding of the Probation Order with a Condition of Treatment. The CPN did not fulfil his responsibility in the continuing need to supervise P and provide ongoing care whilst the Probation Order was extant. There was little shared understanding of the different roles and responsibilities of primary care staff, members of the PCLT and the Probation Service. Consideration of P's risk to himself and/or others did not appear to be sufficiently taken into account during the 15 months that he was in the care of the Inner City PCLT. Management of the Care Programme Approach (CPA) was confused, especially with respect to the role and responsibility of the care co-ordinator. P's lack of engagement with services should have led to a case conference and possibly a referral to the Assertive Outreach team. We were concerned by the way in which a few nurses in one part of the Adult Mental Health Services team appeared to work outside the management framework. They appeared to hold managers in contempt and at the same time were able to circumvent proper lines of management when it suited them. Nurses are both professionally and managerially accountable for their actions in completing their work and should document their interventions with patients in appropriate record keeping. For a variety of reasons much attention has focused on the nurses in this case but, in our view, managers at all levels in the organisation must take some responsibility for the poor functioning of the team in question. Senior managers were poorly advised to adopt a 'hands off' approach when breaches in nurses 'code of practice' occurred, notably in the management of the outcome following the audit of record keeping in 2000. Both clinicians and managers have a shared responsibility to provide services which protect patients and the public through appropriate care plans. Unless there is good communication and a mutual understanding of how this can be achieved, services, as in this case, will fall short of what should be expected. Multi-disciplinary discussions would have allowed for more critical appraisal of the management of this case and the desired outcomes. Comment Inquiry Mackay; P back to List of Inquiries Home Page   back to Inquiry Link page       E-mail reaction is welcome mica@didgy.freeserve.co.uk