M ental I llness C oncerns A ll	Said by his two sisters to have been odd since thirteen years of age, they maintained a realistic view of his subsequent conduct, avoiding close connection He left school with no qualifications and never settled into various short term unskilled jobs, with long periods of unemployment. Aged twenty-two he began to experience thoughts being put into his head and that his thoughts were being controlled from outside. He saw the family doctor who recognised mental illness. AA declined a referral for psychiatric advice. Shortly after a psychotic absence in the Isle of Wight later returning home he stabbed a theology student whom AA knew, who was trying to helpAA Found not guilty by reason of insanity he came under the equivalent of a Hospital Order . On remand awaiting trial, AA received depot neuroleptic medication with a good response, and when transferred to a Special Mental Hospital he was free of symptoms, described by his father as 'never as well for 5 years'. His medication was withdrawn for observation of any recrudescence of illness. In September '98 he told a Tribunal Review Appeal that he doubted he still suffered from mental illness. Two months later he 'was more bizarre and withdrawn' and later 'preoccupied with religion he once stood up and said he was jesus'. Depot medication was reimposed and he improved. But he always denied he had ever relapsed or that he had needed medication. A year later he is accepted for transfer to a Regional Secure Unit, still reluctant to accept medication but maintaining improvemnt and therefore recommended to go forward to conditional release. Accompanying his approval of this move on, the Responsible Medical Officer at the Secure Unit wrote two letters to the Home office ... " AA should never be made subject to a full discharge from a conditional discharge, as he will take the opportunity to stop taking medication".... It is not clear if this was recorded in a transfer summary or letter. AA left to stay in a Hostel, coming under the care of a general psychiatrist and the local mental health services. He began to complain of side-effects from his depot regime ( Piportil - a different one from that started in the Special Hospital - clopixol .. when the change occurred is not stated in this Report. ) First reduced, the side-effects still being reported, the depot regime is omitted, and replaced by an oral equivalent, sulpiride. AA applied to Review Tribunal for an absolute discharge from conditions, and this was supported by his consultant psychiatrist who did not appear to have seen the comment ( noted above ) of the doctor from the Secure Unit. AA had been on oral medication apparently succesfully for a year. The Tribunal would have had the opinion from the Secure Unit before them - from the Home Office. The Tribunal accepted he was free of symptoms and that he would keep to his medication. In fact he slowly deteriorated, showing the signs that gave foreboding of illness. He revealed none of this to his psychiatrist, always said he was taking medication, and the psychiatrist confirmed from the family practice that AA was picking up his medication on time. His condition then was variable and at times he did acknowledge illness symptoms. He was advised to increase medication but he declined - for possible side-effects. He put off a trial of the newer preparations. His psychiatrist introduced a newly formed community team that could be more assertive in claiming contact. Over one Xmas time, his behaviour was such that a sister left early to her own home, and his parents barricaded themselves in at night afraid he would harm them. At a consequent early appointment he presented well and declined an offered admission but accepted an increase in medication, and closer interviews with the Assertive Contact Team. His psychiatrist felt there were insufficient grounds for MHACT detention, and that even if she recommended admission, the Approved Social Worker would not have agreed; and AA would have been alienated from future cooperation. He continued in the care of the assertive team never very ill, never very well, but generally showing well at formal assessments. He asked for admission twice, the last time describing violent thoughts to a community team member, and requesting the depot regime. He had one injection on the ward and left the same night. He was visited by two members of the community team the next day when he was more settled, and having had a depot dose, it was thought he could manage to continue. He did not turn up for a second depot injection, and failed to keep an Out-patient appointment , then for a few weeks could never be found by the community team. He arrived one day at the team base, asked for medication and was given a prescription script. A few days later he killed his father. The Inquiry Panel records ... in hindsight it can be seen that these three factors ( absence of information about the view of the Secure Unit doctor to the general psychiatrists: the decision to change from depot to oral medication: the decision of the Tribunal to grant the absolute discharge ) meant that AA was in control of his medication and so was in control of the progress of his illness , even if he denied he was ill. Reviewed	E-mail reaction is welcome mica@didgy.freeserve.co.uk