M ental I llness C oncerns A ll	Summary and Comment Inquiry Bhatoa; A His early childhood experience of sexual abuse and harsh upbringing from his father who had strong opinions, led the ancillary professional mental health service staff later to believe that subsequent unsocial behaviour and aggressive social interchanges arose out of residual resentment and a general feeling of getting his own back on those whom he felt to be in any way related to his early childhood abuse. His resentment sometimes settled and persisted on some people seemingly singled out for a particular memory, although there was no substance or basis for the resentment His many and various various police engagements and prison experiences, led him to be assigned to an idiosyncratic 'forensic' unit which seemed to have no clear view of its purpose other than it handled those with criminal contacts. The Consultant psychiatrist seems to have gone missing in the sense that psychiatric thinking, a reconsideration about psychiatric illnesses, was not continuously engaged. His abnormal behaviour was put down to his unhappy childhood, the aftermath of a serious head injury, with the additional explanation of the influence of cannabis and alcohol. The experience and observation from his caring mother who remained closely with him all his life, was downgraded and ignored as non-professional observation, in favour of the professional contacts which misled themselves into trying to establish links to his early experiences - to be somehow worked through and out. 'Illness' does not seem to have come into anybody's mind set. It looks as thought everybody thought in terms of personality disorder subsequent to bad childhood experience, to an extent that obvious psychiatric facts were downgraded and ignored – because they did not fit in with the general style and modus of 'the Unit' 'A' eventually presented the evidence for schizophrenia. His mother could have told them . The evidence for schizophrenia had to find acceptance and to be a basis for worry and basic concern. But this seems never to have registered as a serious pointer to a thorough psychiatric review with the psychiatrist pressed to make a diagnosis, or to account for the mis-beliefs on some other reference matter. The clinical supervisor and chief mental health involvement was with a Psychologist, not a medical psychiatrist. The frontline worker was community psychiatric nurse, who answered to the Psychologist, not to the psychiatric lead. Neither the Care Programme Approach nor the regular attendance of the Psychiatric Forensic lead at Reviews were rigorously followed. Quite dreadfully not taken into substantial fact, , two months of medication against schizophrenia or 'psychosis' – a sufficient 'trial' of diagnosis - did have a clear efficacious response. 'A' then refused to continue with it, Nobody seems to have felt there should have been a change of lead intervention, a change of mind , a change of attitude , a change of management away from 'psychology', to the 'medical model' of management – medication. . His mother had long experience of A and his mis-beliefs. She was never asked about her experience of caring observation , in the way that would have shown up A's longstanding mis-beliefs. She probably believed that 'they' – the professional system knew best, they must be able, that's the way they work, to know everything they need from their interviewing - otherwise they would have asked me for my observations. They would have asked her, if they needed to know, about what she saw going on and living with – they were the professional people - and so she just struggled on and put up with an awful life. 'A' by chance came across 'B' who had some connection with the remote setting of the earlier abuse A had experienced but was not a direct participant in any way. The circumstances point to mis-beliefs and a wrong attribution of blame and retribution. It was A, when ill with schizophrenia, who killed him His schizophrenia was not looked for as the important thing in all this – a chance for effective treatment. That was not recognised as the outstanding weakness to be addressed, , not ruminated upon as working pathway, although he was in the hands of a forensic psychiatric Unit. How could this happen ?? back to Inquiry List back to Home page.   back to Inquiry Link page       E-mail reaction is welcome mica@didgy.freeserve.co.uk