Comment Hanson; JW The family asked for this independent Inquiry, particularly that pressure on beds may have led to release too early from hospital, or because of Xmas in the offing. JW was a man with very aggressive behaviour when ill. Also a difficult 'case' to manage successfully, toward maintenance medication. The original diagnosis of bipolar was later accepted as wrong, and the diagnosis of schizophrenia was what lay behind misbehaviour. That diagnosis together with the burly physical presence, and the violent outbursts means that 'risk' to others was always to be considered. The carer was to be his grandmother. The ultimate discharge was to be with her after discharge from an in-patient retention of one month during which medication was complicated by a balancing of oral switching to depot medication shortly before discharge ,which was to be early in december leading up to Xmas. Technical issues of the time it would take for depot medication to take over from oral preparations means that it was likely that the first depot injection at the time around the final discharge was unlikely to be reaching the blood level at the level of efficacy that the previous oral medications had achieved. The Panel concludes, in hindsight with the tragedy in mind, that this means it was likely JW was keeping relapsing signs to himself, and that the final killing of the grandmother was by JW in illness. The family had not seen illness behaviour at Xmas. JW had said something about harm to the grandmother during one illness episode, but that was not reiterated. The post discharge Out-patient appointment was for 6 weeks forward. There was a visit within the 7days after discharge. That national guidance is good, but it can be too reassuring, as here when medication is being in the process of changing. A first depot can release an early satisfactory blood level, but then fade away rapidly. Subsequent guidance ( the Trust medical director notified the appropriate authorities of this experience ) was that this particular depot took quite a long time to stabilise a sufficient blood level of efficacy. That was not the guidance at the time of the tragedy The community management here does rely on carer to be able to notice and react upon evidence of illness returning; again, the professional advisors and care team rely upon the assurance of lay people that they can cope. Lay people cannot predict future relapse, cannot know the importance and significance of early changes in behaviour, especially where, as here, the patient has rapidly become ill, Professional service has immediate access to response, lay people have the difficult task of knowing when and how to invoke this in emergency, and often with what kind of talk and behaviour that warrants a request for a response. Professional care can take pre-emptive reponse , and lose nothing by being mistaken. Lay people are exposed to recrimination. The point of these Inquiries is to learn a lesson where that can be presented. Here, it is that in an illness of this nature where illness influence may be unexpressed, with a story of illness aggression, means that carer needs more than the usual visiting and contact provision; and that greater duration of care over medication in hospitalisation, is taken to reach predictable medication blood levels of efficacy and effectiveness, at the time of discharge. Here it was vital. Questions remain. Was it appropriate for JW to be living with this grandmother , for her to be the intermediating influence, in deciding and inplementing about putting JW back into the system. Was there not alternative accomodation. JW , when ill, was a difficult man to control. Was there no apprehension about JW becoming ill, whilst living with her. Was she given any indication of what could happen to her ? Was enough consideration given to the fact that JW had no structure in his daily living. No 'recovery' programme, for aftercare. Nothing to do or look forward to. Might this have not given rise to active inquiry about street drug access and usage. back to Inquiries List