R. had been an in-patient for three months at the time of the tragedy. The victim was a member of the staff on that Unit , picked out by proximity rather than for any personally directed reaction to the victim . She was just part of the professional service he resented .He was receiving appropriate medication. He was being re-established on a depot medication maintenance regime. The particular preparation used was changed .There had not been enough time to be sure steady and successful therapeutic blood levels to have been achieved . But progress before and after this admission suggests his illness was not much neutralised by medication.
Ever since the initial event - an attack , involving a shotgun , on a companion college female colleague - the diagnosis of schizophrenia - had been applied ; and that was confirmed after he was sent to a special hospital where he passed three years. He was then assessed as having responded sufficiently to medication, so as to be able to transfer a more local medium secure Unit and then to his local mental hospital service. The transfer was left with restricted options by the conditions of a Home office restriction Order . Medication levels by a depot regime had stabilised , but with some residual side-effect troubles never resolved.
He came under the supervision of a consultant who began to doubt the original diagnosis. As he found R. at Out-patient examination, and when he saw R. in hospital, he concluded it was a personality variation. Others who were with R. thought differently, especially his parents, and other professional staff had reservations. What the Consultant doctor decided, however, was what mattered most.
Eventually, and following a misunderstanding at a Mental Health Act Review Tribunal, which took a wrong decision on the Responsible Medical Officer consultant diagnosis alone, he was released from any Home Office restriction, and then was left discharged from hospital, as an ordinary patient , whose co-operation with disclosure was necessary, and whose wishes about such things as to no contact with his relatives and landladies, would be followed.
This is what the father reveals in a quote from The Falling Shadow - the book of the Inquiry proceedings.
Clearly the staff at Moorhaven did not realise how ill he was, but as soon as he was released and came home, at the beginning of October 1986, it was immediately apparent, not only to us but to all our neighbours and those who visited the house, that he was very ill indeed. He demanded to be sent abroad to escape 'the Nazi dictatorship in this country' and he seemed to be in a constant state of fear, locking and bolting doors and making sure the curtains were tightly drawn, and he complained of being radiated by nuclear rays which he said were being directed at him from Devonport dockyard via the television or radio. If we switched on either he became very disturbed. The Chernobyl disaster triggered this off. He kept telephoning people all over the country, including the Prime Minister at 10 Downing Street, and when I put a lock on the instrument he broke it
Sometimes he would pace up and down in a very agitated state, and at other times he would wander outside without any shoes and stand motionless in the rain for long periods of time, and once he sat slumped on the bathroom floor for several hours in a catatonic state.He would cry out in terror because he thought flames were coming through the floorboards or he was being shot at through the window .
Afterwards he seemed to have no recollection of these events. That is ... In a different place, to an examining doctor he did not, and could not, relate these events at a later time.
and this follows " It was early in 1985 that medication was stopped
We were not informed of this and Andrew told us nothing but within a few weeks we began to notice a change in attitude.We arranged an interview with Dr Conway on one or two occasions
but unfortunately Andrew was present and it was impossible to voice our concerns.Now there are two limitations.
1.The patient cannot recall his illness.
2. Those who observed its florid state are shut out from reporting it.
These will be compelling themes in subsequent Inquiries and surface again in discussion about a new Mental Health Act . How to assess the capacity in a patient where there are the limitations of their own ability to relate and recall their behaviour in-between point examinations, especially if the patient debars the family from filling in the gaps.
In fact Guardianship has no real power to impose removal to hospital or to insist that medication regimes be adhered to , but it seems that R. having given his word to the agreement , he accepted the obligations surrounding his life in the community under the guardianship order .
Some difficulties remained . It was never clear, how an independent view of his community progress , coming from people , other than from the snapshot sightings of R. were going to be taken into account and fitted into the programme .
"..... it was difficult to work out who was ultimately responsible for him. "
This period under guardianship was considered by the Inquiry to be the most succesful way of proceeding with the care of someone like R.
Unfortunately , after two years , the consultant in the team knew he would be leaving his job. At about the same time the social worker who was the named Guardian , was to leave his post , and the area .
The community mental health nurse also was to move on . There was no natural replacement procedure .When a Consultant in the National Health Service moves on there is a gap , covered by temporary locum appointments , without the same knowledge or experience of the past story or of familiarity with other professional colleague habits and working practices .
The authority experienced by R. was reduced to the state enrolled nurse who delivered the depot regime , who did not have the equivalent backing of the previous team supervision . Gradually R. achieved the aim of reducing his depot drug dosage regime , and eventually it slipped into his being without it altogether . Signs of the illness recurred without a decisive intervention being achieved, until R. was invited to be seen at the local mental health Unit , where a detaining Order was applied immediately , and he was admitted into hospital, undoubtedly surprised ; and perhaps, distrustful and determined, resentful against what he felt he had been enticed into, and betrayed .
The Admission Unit which accepted him had been the object of a previous Inquiry , a year earlier , into what were found as deficiencies in the ambience , the general hospital setting, and the practices and structure in the Unit and inter-agency community arrangements . The same panel was invited again to report on this disaster that followed .
In his preface after the conclusion of the presentation of the Report , Blom-Cooper alludes, without definition , to the need to look more closely at what he calls 'the philosophy behind the concept of freedom ' underpinning the 1983 Mental Health Act
The Inquiry again noted the difficulties community people, particularly family here, had in putting in their experience and observations into the professional loop .
It criticised the practice in the final admission Unit, whereby the ward nursing hierarchy had the ability to allow leave without (as is required by Mental Health Act ) the Responsible Medical Officer being notified , and allowing the ward staff not to be aware of where R. was at any one time .
It encouraged the application of more supervision - to be felt by
all working staff at all levels. This would encourage reflection
and continuous review on current practice. But the Report is unclear as to
how to bring this about; especially for those at the top of the tree, or
those becoming maybe over-assured in their own long experience -
experience which then becomes out-dated in any new working practice. The
Chair meets this difficulty again ( Blom-Cooper;Mitchell ) without giving
any answer.
It examined how it was that psychiatrists had come to be hesitant in
using admitting MHA detaining sections because signs of a recurring
illness were still insufficient for them to decide that the situation was
serious enough to apply these Orders.
The Report concluded - the most immediate consequence for future
practice - that an illness which had previously been shown to reappear
floridly when medication was withheld , could be held to warrant early
Detaining Order intervention, if medication stopped --because there was a
definite prospect of the illness proceeding to a serious breakdown of
judgement control , and to the previous consequences of that , happening
again .
This became the main argument , referred to again in the preamble - at
what point in mental illness does individual freedom have to give
way to other authority .
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