M I C A " A person may lack the experience to know that he/she is inadequately equipped to perform a particular role. " How can they be expected to be aware of the seriousness in serious illnes, when thos who know better, have placed them in the care of people who were known to be unqualified, or were not checked out as maybe being qualified [ the responsibility then rests on those who do the initial placement ? including placement with family carers ]	Comment Inquiry Holwill; RR Two people suffering from Schizophrenia, one of whom [ RR aged 71 ] was known to be capable of rape and violence aginst women, in the context of schizophrenia; the other [ AT, a woman prior resident aged 54 , known to be likely to form an attachment to male friends , meet in the hostel/Hospital which is where AT is killed by RR. The staff at this place was insufficnetly qualified , were insufficently supervised, were without any clear goals, and were not sensitive to risk. RR was receiving depot medication but it's clinicl effect was not given a rigorius review. RR reveived depot injections. There is confusion as to the occurrence or not of the last depot injection before the tragedy, but the tragedy coincided with the timing of least effeicacy from the depot injections. RR said that his 'command' misbeliefs' were evident before he injections were due. It is likley that this would not be observed nor asked about by the relatively inexperienced nursing. There is no indication that they were ever asked to do this kind of observation. Here is a classic comment by an Inspector from the HealthCare Commission !!!! ... “It was custodial type. There was not a focus on rehabilitation. It was a very medical model and lots of people sitting round doing nothing and not much communication going on. It rather reminded me of an industrial therapy unit they used to have in the big institutions.” what does he mean. ??? RR should never have been moved to such a place. Those who arranged the move needed to stress the high risk history, and to question the regime he would be going to and to raise the clear evidence of who might be potential victims. That raised would have led to rejection as the private hospital was unable to give a sufficiently stringent rgime for that degree of risk How is it possible for schizophrenia to receive this kind of regime of aftercare ? Nobody seems to mind that failures, for this serious illness, of the rigorous application in standards of care and treatment continue, and lead into tragedy after tragedy Thoroughness in the work. back to Inquiry list back to Home Page