he was able
to hold down a regular job at a local factory
and was thought of by many as a
quiet and friendly man.
Relatives suggest he was a kind and loving son and
a cherished member of a close family'M' had been referred in October 2001 for a consultant psychiatrist opinion by his
GP
querying drug induced parkinsonism, due to a hand tremor he was
complaining about.
Following a series of outpatient appointments he had been
placed on a reducing level of depot medication
with the intention of ceasing it
altogether if his symptoms remained manageable for him.
in the days leading up to his mother’s killing he had
become very upset
about an incident at work where he had been shot at by a
fellow employee using a pellet type gun
causing a minor injury to his
shoulder.
He made a formal complaint to his employers
and was more
concerned that nothing would be done
because the person responsible was
a member of the family who owned the business.
The incident had caused him considerable distress and rapidly
led to a loss of confidence in himself and everyone around him.
He began to
behave strangely and relatives who witnessed this
believe this incident triggered
the behaviour which was to lead to him killing his mother
.
In the hours leading up to the incident the family made two calls to the 'out of hours' GP substituteprimary care service
As a direct result of his [ paranoid ]experiences he feels at risk
from others and had previously reacted violently as a result.
The root cause of this homicide was: -
The rapid reduction of medication and the way this was managed in the
absence of a risk assessment determined through the Care Programme
Approach.
The contributory factors were:-
• The lack of management of the case using the principles of the Care
Programme Approach by the team reviewing him at the outpatient clinic.
• M was not seen by a consultant psychiatrist when re-referred in 2001 nor
thereafter prior to the homicide.
• The Care Coordinator role should have been taken by a consultant
psychiatrist considering the position of the junior medical staff.
• There was a static formulation of this patient’s illness with insufficient
challenge when seen as an outpatient.
• There was elicited opinion that the reduction in medication was
inappropriate.
• There was no recorded risk assessment documented and therefore no
relapse action plan.
• More effort should have been made to explore additional methods of
engagement with his mother even though he was reluctant to involve her.
• M and his family were respectful recipients of services from the medical
profession and more attention should have been paid to the effective use of
authority and persuasion with M.
• There was no information given to M’s mother on what action to take if she
needed help.
• The use of a Community Psychiatric Nurse to monitor the change in
medication was not explored and after such a long period of receiving a
depot injection the possibility of a short hospital admission to manage any
change in medication was not considered.
• His missed appointment was not followed up, but he was offered an
appointment six months later.
6
• Notes were not routinely available at outpatient clinics to review history.
• The out of hours service was not rigorous enough in their response to the
family’s request for help. There was no ‘signposting’ to services which did
exist.
The out of hours service failed this family on the week-end in
question.
• M’s mother did not receive a ‘Carer’s Assessment’
CommentRemoval of medication altogether should not have been approved by, and it's management left to, the decision of junior staff.
Especially not without a fall back position, and without setting up a clear route in for family and GP to report in and gain an immediate response.
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