M I C A	This is a short florid illness of imploding intensity which announces itself with bewildering aberrant behaviour, rising to acts under delusional misapprehension, arriving without any previous awareness in a family situation after a Christmas family reunion time. Odd behaviour leads the father to encourage a visit to the family doctor on that Thursday evening in early january 1996 (1.)It is not clear that the father has the chance to describe to the family doctor what has been happening at home It should be clear. The next day more alarming behaviour occurs - damage by K-St to the home after his mother has locked him in. This brings alarm to the neighbours and brings in the police. They lay charges so as to take him to the police station as a place of safety but they withdraw the charges when the mother agrees she will call in the medical services.(2.) The family doctor arranges at Friday midday to visit with a local Psychiatrist consultant, in mid afternoon. Neither he nor the family doctor have yet spoken with the duty social worker.(3.) They decide there is enough wrong and enough concern for there to be a need for hospital detention and clo ser management and observation than is possible at home. K-St has drunk nearly a bottle of vodka. (4.) Around Friday at three p.m they make out the medical recommendations and then tell the social worker,but do not speak to her directly. There is subsequent disagreement about whether anything was read out to her - by the secretary to the Consultant psychiatrist not the psychiatrist himself - at teatime - about any danger or urgency. She does not visit the house in time to set admission procedures in motion, because in the meanwhile a family have brought in a friend of K-St. He persuades K-St. to admit himself to the local ( the Maudsley hospital ) prestigious mental hospital service that Friday evening. (5.) His behaviour on the admission ward is as usual in a rather upsetting first admission mental illness ward experience. The illness is likely to be schizophrenia but that this is the working diagnosis for the ward is not stated. (6.) (7.)At some stage on Friday evening the social worker is told by the ward that he is informal but a - 'nurse instigated holding Mental Health Act Section 5(2)' - a three day detention immediately in effect - the equivalent of the police place of safety procedure - has been discussed and seen as a possible coming necessity if an intent to leave occurs again.(8.) Late that evening he takes himself off home, thought by the ward nurse to amount to discharging himself. The nurse telephones the family and will arrange a community visit. Overnight and through the next Saturday morning K-St. is increasingly disturbed, and restless. He wanders out accompanied by his younger sister. Passing the police station he calls on them to take him back to hospital which they do. K-St has persuaded those to do with this admission to accept a document drawn up by him that it is to be understood it is a voluntary admission. It is not clear that this admission was documented as a second admission - with all the procedures for re-examination, diagnosis , and contingency discussion. Early on Sunday he importunes to leave the hospital to satisfy an overwhelming urge to reassure himself about his mother at home. The senior nurse wants confirmation that he should invoke section 5(2) and telephones the doctors. Before they agree to put it into effect K-St has left the ward and hospital. K-St goes home. The ward nurse informs the duty Social Worker and request a visit to the house and an assessment. What is done by the ward to make a follow up preparation is not fully disclosed - sometimes it is a routine that the police are informed - there are routines for absconsion. - but he is an informal patient.(9.) [ K-St never been the subject of a detaining Order so that there are no statutary aftercare obligations ] The father has left for his trip abroad the previous Friday. Only the women are at home. K-St is in the bathroom with a knife,and threatening. Mother telephones the ward and the nurse says ring the police. As the police sirens are heard K-St stabs his mother and himself. Both die. There was never any personal contact between the Social Workers who could administer a detaining Order and K-St. Sixty hours covers the medical recognition of mental illness and the subsequent tragedy. A younger sister in the house witnesses the killings and cannot get it out of her mind subsequently. She charges the service with failing in care - and five years later this is accepted. A fortnight before a court hearing, five years later, the Maudsley Hospital management offer recompense of 500,000£, which is accepted , and the hospital will pay costs.   further Comment	(1.) the first 'point'examination. Whether the father was able to put in his observations and those of the family and friends over the previous days is not a given. It looks as though the family doctor did not have this to help her. Her resume is only that the K-St believes that the vitamins his father has given him may have done harm to him. Perhaps a recognition by K-St that something is wrong. If any medication was offered this is not stated. A sedative phenothiazine would have been appropriate and a second opinion on the agenda for the next day - the day before the english weekend - to consultant psychiatrist and/or social worker - but - only if the full picture had been given to the family doctor. It would be unusually good practice but an unlikely possible for the family doctor to have suggested that father speak to the social services . Not perhaps in the current climate of relationships and respect for out of hours. (2.) Kindly meant but wrong - this was a violent presentation and risk was present. Perhaps discussion with the social work office. (3.) It seems to have been a decision from the psychiatrist not to - for an unprejudiced view - but surely information had already laid down an expectation. Again depends upon what was exchanged in information. All depends upon what the family doctor had said to the psychiatrist and the mother to the family doctor - it looks as though there was enough 'likelihood' from the behaviour at home that the social worker should have been informed at this stage. (4.) The alcohol consumption is probably unrelated as a problem. The ward does not notice withdrawal signs. He is described as a moderate drinker.   (5.)What is an informal admission and how much 'agreement' to be bound by hospital 'rules' has always been an ambivalent position - if they want to go, they cannot be stopped. Having come in 'voluntarily' people are wary of then applying detention. [ In the good old bad old days voluntary admission undertook to give three days notice of leaving ] But much 'covert' coercion lies behind 'informal' admittion - the 'or else' often applies. It remains a miasma and difficult for staff to contend with, unless they are 'prepared' and clearly led for the circumstance - not the case here. Nurses have their own supervising hierachy - but this is the week end - and staff do not feel comfortable at being seen not to be able to take their own decisions. ( A.Joseph )The nurse does not have to consult for Section 5.2 but seems to have needed clearer advice - from medical notes? (6.)This diagnosis focuses and concentrates the implications in .. 'what do we do now ?' .. situations.(7.) It is a basic ground for detention where there is also uncertain behaviour and circumstance. (8.) It would have made this decision a more acceptable one and one more comfortably made by a nurse.       But surely by now a detention order based upon the initial recommendations and the further observations was necessary. Even if the 'rules' were not known or properly followed a common law basis of defence for detention by faulty MHAct procedures is available. It was right at the time is enough. There should have been a more prepared and better founded and connected relationship with Social Services mental health departmentso that this kind of critical decision process would have had a previous practice of mutual consultation to be called upon   But the LASocial service mental health teams have long since left the hospital based teams. Consultants, nurses, and social workers no longer have mutual understanding through regular meeting together in teamwork, and the personal inter-change of feelings.     (9.)The police might well have been informed about the decamping earlier - and the social worker, and advice given that someone else than the women should be in the house. Because no one else but the police could carry the authority they should have been informed directly from the Ward by the Duty doctor representing the Consultant. They had been discussing detention orders so might well have been apprehensive enough to see that some protection was necessary. reviewed   Not the end of the story Mail To :_ mica@didgy.freeserve.co.uk

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