M ental I llness C oncerns A ll

M I C A	Until it goes wrong The Maudsley Hospital - as it was - the Institute of Psychiatry - a leading post-graduate centre of theoretical excellence - has had to come to terms with working for a catchment area, doing everything there, and establishing community working. It has had to commission whole services,and provide completely for a locality, and a function ; delivering it in working order. And cope with many management changes in administration.   This Inquiry looked into the care provided from its Forensic Service. The findings were issued in two volumes - 560 pages in all, and a separate summary. A Medical Director of the Institute sat through some of its hearings, and was upset . L-W-L is one whose service care failed to keep up with him, out of many who were helped by it. The parents of LWL are of caribbean origin. In his family he is the eldest of a four boys in the second marriage of his mother, borne and reared in this country where both his parents had regular work, and a steady home in South London. His childhood was ordinary. He was not a scholar. The family kept in touch with him although not always within an easy relationship, in his after school years. He left school with no qualifications,and was soon in trouble,beginning with a sex offence when he was at school,after school hours, aged fifteen, in the company of other boys whilst at school, with a girl under 13 years. A later charge of suspicious behaviour was related to car offences. Again in company a later similar charge arose out of harrassing girls, maybe together with stealing. Eventually for this and the earlier offences,after a failed appeal for the first offence, he went to Borstal, and after release and a further minor offence he went to Prison for three months , followed by Probation. Probation was unsuccesful, LWL refusing to recognise the authority of the Officers, changing them often. One Probation report observes some bizarre conversation. He seems to have lived with more than one girl friend and to have two children by the different liaisons. A last one rejected him and changed the name of the baby from Folkes - his parents name. Around this time he became different, and his behaviour harder to understand. During the course of the next three years between twenty and twenty- three, it becomes clear he is suffering from a variable degree of the illness schizophrenia. He has been violent during this time, to his mother , into destruction - at home, and subsequently towards the many police officers and assistance during five or some admissions under Section to local mental hospitals. The diagnosis took time to be firmly stated - because his symptoms were negative and withheld, but three years into his illness, there was a time when he described clearly the presence of the illness schizophrenia. The corrective response to medication, and the relapsing without it into misbehaviour - had already been established. The final offence which took him into forensic psychiatrist supervision occurred soon after a demanding and overbearing second visit to the social worker of the homeless Unit to whom LWL had been referred by his mother earlier when she noticed him 'going off'. He demanded money abruptly and without any sense that this was the wrong route for that.The receptionist said he was carrying a knife. In retrospect the Panel notes how similar this was to the similar angry approach asking for money, just before the final tragedy occurred. Outward arrogant abrupt inexplicable overbearing demeanour is a sign in paranoid schizophenia of the hidden delusional self-important autistic communication. On reflection his attitude to Probation was probably an early manifestation of that. The next day in the open street, he slashed several people in that street with a short cutting edge 'knife. Arrested and remanded , a Forensic specialist commented - " unless under detention at the start of his treatment, he might well leave and pose a threat to himself ,and to others. He had denied his mother was his parent - which he had also said during an earlier illness phase, when he had attacked his mother. Neuro-leptic medication settled his illness in hospital so that after his transfer to the Medium Secure Unit at the Maudsley, they did not always see the florid illness. LWL recognised his earlier convictions were misbeliefs.	This is an illness which responds if medication is taken consistently. In the medium secure Unit he presses for reduced medication and eventually is granted that and a period without medication altogether. Isolated expressions of clearcut illness behaviour are noted, but these and two incidents of violent expression do not bring a resumption of medication until after two periods of absconsion. The clinical lead request his transfer to a special hospital saying his threatening demeanour to her and his general behaviour were beyond what the medium Secure Unit could manage. He was three years there and although he was containable in that structured environment, there were apprehensions in his behaviour towards women and his attitude towards his medication. Returned to the medium secure Unit he is established on depot medication and oral neuroleptic drugs, which he immediately set about requesting be reduced. His illness returns. There is one interview which is very clear about this but LWL does not recollect what he has said the next day. The resulting return to illness is episodic and not florid. It is eventually noted and medication resumes The depot medication gives him side-effects. A Tribunal Review is specific. "He suffers from a mental illness which however is well controlled by medication.He does not constitute a danger so long as he receives such medication. Continuance of medication is essential for him so there is a particular need for supervision in view of the patient's doubts about the benefit of this ... He is granted conditional discharge. Less than four months after his discharge to a Hostel and a day attendance , he succeeds in challenging and omitting his medication. He is able to persuade the Forensic team that his mother is a problem for him ,so that she is cut out of the aftercare picture, and any observations she may make are discounted as biassed against LWL. She is right in her observations, that he is increasingly abusing cannabis,and deteriorating in his illness. The neglect of carer observations is a frequent comment in other Inquiries. He turns up at an electricity supplier to make a muddled request to recharge his electricity key, at night, to the bewildered security guard and beats him near to unconsciousness. Many police are called to overpower him with great difficulty and much force. In the Police station a Police surgeon says to him he is not mentally ill. That also is a not uncommon experience in other Inquiries. The Security guard is illegally in this country and does not want charges to be pressed. LWL goes clear from the Police Station and goes to the Emergency clinic at the Maudsley Hospital, who have been advised by the Police. The Forensic Consultant advice is that he be offered a bed next week or so and offered a depot medication. He might be admitted on an Observation Order. LWL left the Clinic having taken 20mg of the oral neuroleptic drug stelazine. Forty-eight hours later - declining to allow a visiting party in to deal with him - many police are called and he is admitted to the Secure Unit on place of safety Order. He settles and some months later a second Tribunal grants him a conditional discharge under conditions very similar to the ones previously imposed. Eventually he will again persuade the Consultant - who complies because of the need to maintain a position of trust and alliance -because the relationship may have to be for a long time - to change to oral from depot medication and some months after that, the final tragedy happens.The day before the final tragedy he has turned up at the base hospital muddled and demanding, telephoning the Benefit Office. His unsettled behaviour calls in a rapid reaction nurse team.The Consultant when telephoned advises detention. Those called to observe him in that Out-patient setting do not find either grounds or the authority to do so, and he eventually departs disgruntled. An assessment home visit is arranged for the next day. When a girl-friend who does not know the seriousness or the name of his condition, visits him in the early hours she is attacked and dies. A urine sample taken on arrest tests negative for medication. Review Scotlland; LWL ( foulkes ) E-mail reaction is welcome