M I C A	Paul Leane ( PL ) was an only child of a single mother , brought up in circumstances rather isolated and rather separated from most of the extended family support system of his mother. There was one maternal aunt in reasonable close touch. He seems to have kept largely to himself during childhood and during secondary schooling from which he left with basic qualifications and then entered employment with a telephone company. Six years in the job, around the same time that his mother was found to have cancer he became dispirited about the strain he felt at coping with work and saw his family doctor. He felt uneasy about the loosening personality, and he felt he might have schizophrenia. Nobody whom he saw about this perplexity heard anything from him which they recorded as supporting that diagnosis, and he was thought largely to have an inadequate personality and be too reliant upon the supportive company of his mother. She recovered her health. Some early rumination about his sexuality seems to have been put down to adolescent concern, although he was rather old for that to be just ordinary and usual. Referred to the secondary specialist mental health services there was never a clear working diagnosis and therefore no clear treatment plan. Not even a fallback recognition that the case was not 'solved' and should be reviewed again, or perhaps looked at with the kind of information that would come out of the witness of those who knew him well - his mother and her sister. He later could not cope at work and left, subsequently re-instating in a lesser post, but then giving that up and living at home, living off his savings for three years before seeing somebody professionally after an overdosage of aspirin which required alkaline perfusion. Perhaps with some little apprehension and uncertainty of the underlying diagnosis on the part of his professional advisors, he was prescribed stelazine. This is a drug given primarily for schizophrenia, but did have a vogue and a commercial push as an anxiety treating medication which was not sedative, and was not a risk for overdosage- often the priority thought in the mind of general family doctors . It was sometimes prescribed for such anxiety - in low dosage - the one milligram preparation - to avoid side-effects of parkisonism. The fashion has passed away, so that only the 5mgm dosage is still generally available - any increasing dosage of that would move it to the level towards managing schizophrenia - and here what was prescribed originally is the single dose 5mgm aimed at uncertain anxieties. There may have been some acceptable expression of usage from PL as the dosage was subsequently increased - by the general practtioner, without explanation for this - reaching into the anti-psychotic range - to 5mgms three times daily - a dosage in the range of effective treatment for schizophrenia. But that diagnosis was never made. Mild symptoms were continued to be recorded, insufficient, in the eyes of professional appraisal, to warrant the attention which PL wanted from them. It was not reflected that this might indicate continuing matters undisclosed and unexamined. It was felt his persistence with professional contacts was partly to preserve his benefit position and to gain protection from pressure to return to work. At one stage a serotonin inhibitor anti-depressant medication currently in common family doctor practice for anxiety/depression was added to the stelazine. It was all rather vague. Not well but not ill. Subsequently a revisional assessment decided that either the stelazine or the anti-depressanrt should be the sole trial preparation. The decision was for continuing and adjusting the serotonin inhibitor type anti- depressant. It cannot be certain that this was taken . Some five months after the stelazine was stopped, he poured petrol on the floor of his home and set it alight - to kill himself to escape persecution - he later said - but the flames went the wrong way, and his mother it was who died from the fumes of the fire. After sequestration in a medium secure Unit, the note of admission there - and what he subsequently said to the visiting Inquiry - points to the diagnosis of schizophrenia as having underlaid all the previous presentations. That was never the working diagnosis. Although ironically - and tragically - he did receive some medication appropriate for that condition - which would have 'covered' that illness and might have blunted its full expression to observers, even professional ones. Home page Comment

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