M ental I llness C oncerns A ll	odd man out JP has been through two marriages, ending in divorce, from which there were six children. He then took up with a much younger woman who was a single mother with two children. This failed and when she obtained a house of her own from a housing list she left for a younger man - an eventual victim. The father of JP was an immigrant Italian, who succeeded as a farmer. JP was brought up with that and his own especial interest became horse management and breeding. At the time of his developing illness, he has returned to the assistance of his family of origin, from whom he then obtained the resource to take on a farm which supported sixty horses. He is involved with this when his liaison finally broke down. Sometime previously there is an incident where he is threatened by someone with a gun, that person being subsequently charged. JP is known to possess a shotgun. Indeed he is fined for not having the appropriate licence. JP has criminal record for minor theft and for more serious theft charges, subsequently. But there is nothing currently against him. Little is recorded in the Report of a previous history of life difficulties showing personal mood changes. Nor is there a family history. He is described as usually convivial and outgoing. This changes during the eighteen months leading up to the event. He becomes introspective, hesitant and indecisive, not sleeping well and falling into a ruminant unfinished odd kind of attachment - the one rejected - to putting himself in the vicinity of his last woman friend and partner. She eventually reports it to the police as harrassment. He is sleeping poorly, worried - according to his family about cancer - although he does not reveal this to his family doctor. He complains to him about depression, and receives a prescription for the non-specific so-called safe anti -depressant mood shifting medication - serotonin altering drugs - first 'prozac' and subsequently another in the same class. The specific tri-cyclic anti-depressants are not tried - probably because of the danger of overdose in someone living by himself, and, in the same context, the early off-putting predicable presence of troublesome side-effects The depression never leaves him entirely. His preoccupation with his last woman partner leads him to bother her with his presence, over quite a period of time, which eventually leads to an altercation and police intervention followed by a car chase and then a 'charge' to be answered in Court . This weighs on him. It is the progress of this charge together with his continuing depression which leads to his referral to the specialist psychiatric services. The family doctor refers him to a community mental health team, one composed of mental health nurses only, for a prompt response and as a preparation for the other referral, made at the same time, to the catchment area Consultant psychiatrist. The Court, later and separately, also ask for an expert comment from the same Consultant. The referral to the community service is not immediately succesful , partly because the surgery and family doctor give a previous home address.This takes three weeks to correct. The nurse assessment is finally achieved on the day of the court appearance, in unsatisfactory circumstances. Something about the level of anxiety shown by JP seems more than expected in the context. The nurse is bothered by what he sees during the interview and later calls in a forensic nurse colleague, with greater experience who has also run a succesful risk assessment programme, for a more experienced opinion. This colleague sees him a week later in the company of the junior doctor in the Consultant team, the junior doctor being designated to receive this new case, by his Consultant after he has received and checked the referral letter from the family doctor. The forensic nurse has a second interview, a week later, together with a probation officer who is to prepare a report for the Court. They, too, are struck with a feeling that all is not revealed to them. They advise an expert opinion for the Court - from the Consultant already approached by the family doctor seven weeks earlier. It is this which brings about a date for the Consultant appointment. The first appointment, to the junior doctor, which is not discussed by him with the Consultant, before or after the appointment is kept, comes from the decision of the Consultant when he gets the letter from the family doctor referral for Out-patient appointment, so that after reading the referral circumstances as far as he can, including the matter before the Court, he assigns the case to his junior doctor. The Consultant is a busy man and has adjusted to this by delegating some of his first contact work to the junior colleague. The junior colleague has no psychiatric qualifications, and only a short experience in psychiatry. Neither the Consultant nor his Office pass on to her the Court charge information, nor is there any direction or discussion before or after, as to how to proceed. This is left to the junior to determine and decide. A new anti-depressant medication is offered, and side-effects reviewed to overcome a reluctance to try yet another medication - to follow those which have had no enduring success. A reassuring appointment is made for the next week; and the one with the Consultant made in response to the Court request, is confirmed for a fortnight hence. It cannot be kept because the tragedy has occurred. His father, the rival , and Piccolo himself are shot and killed.	back to Inquiry List E-mail reaction is welcome Home Page mica@didgy.freeserve.co.uk

Review Bowron; Piccolo