M ental I llness C oncerns A ll	NG qualified as a Pharmacist . The illness of schizophrenia started to affect NG at the time he married , and after a car accident . The marriage ended five years later by divorce . The diagnosis was made the year before . His mother died in the same year . Two years on from the diagnosis, his pharmacy business failed after incidents which led to his licence to practise being withdrawn. NG was helped by his father who arranged to take over his house - a matter which afterwards came between them - and helped NG to sell his business. In the same year NG threatened his wife with a knife and tried to remove his son. This led to a psychiatric assessment and detention in a mental hospital under a Treatment Section of the Mental Health Act. NG would then be subject to aftercare arrangements after discharge. This began with a follow-up out-patient appointment in a London Health Authority catchment area in London, after which his future care and contact was with that service . A housing association found him a flat. There followed three admissions to hospital over a period of three years. One of these was after an assault on a police officer during a magistrate hearing. As a consequence of that there was to be a later different magistrate hearing . A Probation Officer invoked medical recommendations and NG was admitted to hospital instead , and the Court case was never proceeded with. He continued to attend Out-patient appointments, and for a spell attended a Day Hospital , nominally under a different Consultant . A brother kept in touch . The father was estranged and was attacked once by NG, but remained involved, generally through, and with, the brother . On one occasion they were both invited to a Care Programme Review meeting, formulated by the Social worker who was the key worker during the last two years. They presented themselves on time but without complete directions, so were unable to reach the meeting place on time, the Consultant having left. They spoke with NG and the social worker, the father getting the impression NG was still ill, was against NG being released. He commented ... either he will kill himself , or someone else .. Because NG was seen at a Day Hospital, he was not registered with a Community mental health nurse service, although when he left the day Hospital to a sheltered work placement , a referral would usually follow. The key worker elected to keep contact, judge progress and arouse any other care change, was a Social worker in the local Authority Social mental health service provision. The Social worker received several complaints from neighbours against NG, about noise and other odd and upsetting behaviour. In the same period, the people at the work-place attachment became frightened of his behaviour there. At a drop-in facility NG went to, they also noted he was 'loud'. The social worker had noticed illness behaviour on a visit to the flat to see NG. It was not seen as warranting consideration of a MHACT Section hospital admission, nor sufficient to ask for a review or contact the psychiatric service. The reports from the workplace and drop-in centre were discussed by the Consultant psychiatrist and a trainee doctor at the day hospital. A community team nurse was then called into the care programme. She did not know him from before. She saw no disturbing illness. She did not speak with the key worker. No professional realised that he had stopped taking his medication. In a car-park NG drove his car at a passer-by and killed her. back to Inquiry Links E-mail reaction is welcome mica@didgy.freeserve.co.uk

Review Main; Gadher