M ental I llness C oncerns A ll	These Inquiries try to follow the relevant issues which led up to failure. For suicide and homicide, as an outcome, is failure however much it was not foreseen as a possible subsequent event, so that there was no blame to be put at one or other aspect of care. From the point of view of a family carer we are looking at an agency giving community care to a family member. One agency - the NHS - is providing illness care to DG for a recurrent illness which neither DG nor his wife have the expertise to deliver, nor understand unless fully guided. Another agency - the Local Authority Social Services are providing social care - relief and expert advice about the management of the son with mental handicap and some physical deficiency as well, whose burden of care is mostly at home. The agencies meet in a joint community mental health team - for there are social workers in that team [ but not those immediately involved with the son with handicap ] which meets together, discusses together, and delivers locality care for those in the community who need it because of continuing liability to serious mental health disability. The psychiatrist in the team was a long term locum consultant psychaitrist The Inquiry report recommends this be filled on a permanent basis. A locum cannot carry the authority which comes with permanent commitment to, and identification with, the development of local service and to the future. Somehow, the importance of the early threat about homicide and suicide did not continue to be held as dangerous by whoever was in charge of assessing and providing the social service intervention required to keep the son managed at home. It is likely the threat that a thought intention might be carried into effect when led by psychotic depression wa not a warning for increased vigilance and the need to give the wife, whowould then be the principal carer and observer, the route in to obtain prompt intervention when DG should be come ill again.The social service is criticised for not appreciating sufficiently the increasing strain upon the home care, by the physical illness of DG, the worry about the possibility of a return of mental illness in DG, and for not appreciating the change to parenting worry and the responsibility that this imposed on both parents , who were ageing and also uncertain of continuing strengths, and faced with a son becoming less capable and physically more frail. It is likely the Social Serrvices concluded that DG was recovered from his mental illness, and therefore was fully returned to his supportive role. Nobody told them differently, which means there was insufficient information in the disseminated information after DG was discharged fom hospital. The GP, the Social Services, the community team including the social workers, should have received information, which pointed to an uncertain future and the necessity to take aftercare precautionary steps, one of which would have been to secure possible future contingency arrangements to monitor properly, to intervene promptly, and to change and improve the balance of home and relief care. The principal person to consider in all this was the chief family carer who had become the wife, and she should have been given and told how to use, much better channels of early help and communication for her. As is very common in Inquiries after Homicide a person in th community, most often a family member is in possession of observations about a deteriorating care situation, but there has been no prior attempt to lay out easy ways of getting that experience and observation into an agency service which could deliver a prompt and expert response and reaction. Something missing from this Inquiry report - again very commonly missing, is an account of the actual treatment given - in this case for depression. It is always important to tell family of the actual detailed name of the efficacious medication, and the fact that when it is once effective, it will be so in any future recurrence. They then have something positive to do at the time of recurrence. The failure here, as so often in Inquiry Reports, is that the secondary agency - neither the NHS service nor the Local Authority Social services - which has the expertise, has given that expertise information to the family carer. It is the family carer who - given the information - will be the first to recognise that intervention is again required. Yet they are excluded from the way to get and give help, in a particular matter. That reassurance was not available nor given to the family. Back to Inquiry Galbraith; DG E-mail reaction is welcome mica@didgy.freeserve.co.uk