M ental I llness C oncerns A ll	KT was unmarried and in work when he began to change in behaviour , living at home with his parents: a mother who suffered severe panic attacks and may have drunk alcohol excessively , and his father who was developing a progressive memory failure , its extent covered by the care from the mother . She died and the care of the father was largely with a married daughter nearby , because KT was at work . KT was upset that his father was at a daycentre and at a carehome , and despite being at work took his father back to the family home , three months before the tragedy . Back-up early day assistance to get the father up for daycentre attendance was felt by KT to be insufficient , and he gave up work and took on the total care of his father in the last year . During this year KT was admitted three times to the local mental hospiotal , with behaviour disturbance around epilepsy . KT had suffered from epilepsy , small and major ,since he was four , protected and supported by the parents he never left . Throughout the eighties he was free from fits .They were more frequent in the final two years before the tragedy . Epileptic seizures may be preceded briefly , and followed , for longer , by odd behaviour . After many years of experiencing epilepsy a condition resembling mature schizophrenia can develop and persist in between 'turns'. The Inquiry reports beliefs about a spiritualist grandmother from whom KT thought he might be receiving directions . KT had an insufficiently comprehensive diagnosis whilst an in-patient in the mental hospital because of the short duration of observation , the lack of florid signs of illness , a lack of focus of consultant appraisal , and the inexperience of junior doctor . KT was seen , after the final in-patient admission , at an Out-Patient Clinic by an inexperienced senior house officer - a doctor in training for a speciality - without supervision , whose experience of the occurrence of schizophrenia after longstanding epilepsy may not have been present in the conclusion . The working diagnosis was left at around fit time phenomena despite evidence for in-between fit permanent changes in peculiar ideas - less so in the in-patient admission history of KT , but more clearly in the Out-Patient attendance after final discharge from the ward . W. Taylor, the ageing father ,living with KT,had his own social worker (A). The psycho-geriatric team had four community mental health nurses. The adult team looking after KT had social worker(B); no community nurses are listed as team members in the Inquiry Report , but they are mentioned as visiting the admission ward where KT was. A 'named ward nurse' is called the key worker (*) In common with many other Health Authorities and Trusts - the Care Programme Approach - a national guidance circulated in 1992 - was taken on in theory by 1994, but not in practice not until May 1995. The Local Authority Social Services , whose similar case management approach is brought into play in aftercare, ( and was supported by a particular central government Grant - Mental Illness Specific Grant (MISC) ) was ready earlier. Two different working mental health teams had knowledge of the situation in the house. Different social services team were visiting both father ( psycho-geriatric Social Worker A - who actually visited KT,s admission ward to tell them about the domestic caring situation . ) , and son . The son had three mental hospital admissions. Three admissions over a short period of time indicates something wrong, and is one of the criteria that should lead to the highest level of aftercare Care Programme Approach. Florid psychosis was not uncovered or considered so there was no direct or immediate concern about domestic circumstances. There was no implementation of a full care plan for after discharge and nothing was implemented -- the aftercare keyworker had been appointed in her absence from the ward pre-discharge discussion . Any sort of detention Order for Treatment should be followed by an aftercare service. At the pre-discharge ward meeting the Responsible Medical Officer consultant left it to Social worker (B) to start her own contacts and make her own report back, without any guidance and without having seen Taylor herself or having been privy to the ward observations. Although the works doctor had relayed odd behaviour at work this did not get into the referring letter to the hospital from the family doctor . The family doctor is not invited to take a part in aftercare observation .This is left to the community mental health team and social aftercare. The junior doctor in training notes a peculiarity at an Out-patient appointment, but it is not given any weight, nor is it clear it led to any discussion with the consultant. By now KT has given up work and had referred to the difficulty in managing father.   Management were thought to be 'frozen out' from issues of clinical process, such as the introduction and application of the care programme approach, at ward level. If either of the parties visiting the home of KT and his father had been following the Care Programme Approach, the deteriorating care situation would have led to a review of the caring situation. Home page Inquiry Linking Review Barlow; Taylor	E-mail reaction is welcome mica@didgy.freeserve.co.uk