Inquiry Dale; Holiday { 'B' }
He is now [ in secure hospital ] much improved because
he is receiving medication which can now be consistently monitored
over a
prolonged period of time
and he is involved in meaningful day time activity.
He still has no recollection of the events of the 5th of January 2005.
Carers views were
not routinely sought during or following periods of leave.
The patient
spent a lot of time on leave even though he was documented as being
unwell.
A full ‘Carers Assessment’ should have been undertaken at the outset
and reviewed annually.
There was no evidence that this took place
and it was not clear who should have taken the responsibility for
organizing this.
In view of the severity of his illness more weight should have been
given to formal admission.
no record that risk issues were routinely discussed at the
inpatient multi-disciplinary team meetings
and did not appear to have
been fully taken into account.
it was very difficult
to obtain a full picture from B
of what his symptoms were and how they
affected him.
He was skilled at masking and hiding them from staff
and
said what he thought they needed to hear in order to simply be left alone.
On 4th January 2005 he was visited by the CPN and there was no
reply.
A telephone conversation with B’s mother clearly indicated that
he was avoiding having the injection that day
as he now believed he
could be cured by prayer
and deceived his mother with false
information as to why he was not to receive his depot injection for
another week.
He had previously skillfully avoided his mother’s
involvement in his treatment,
one example being that he would
arrange for the CPN to visit when his mother was at work.
.... the root cause contributing to the
patient’s continuing severe mental disorder was that of ‘under
treatment’.
His situation and condition could and should have been
more assertively managed.
• The patient dictating, in part, elements of his treatment which should
have fallen within the auspices of professional practice.
• Of the six admissions he had over a four year period only one,
which
was of a prolonged duration where he had been compulsorily
detained,
had a more noticeable effect on his mental state.
• There was little attention paid to the testing for the presence of illicit
drugs and no thorough history of his illicit drug use.
• He too rapidly proceeded to leave when an inpatient.
• He was able to abscond and absent himself from inpatient care too
easily.
• He had little to occupy him through the day in a structured programme
when at home.
• Alternatives to living at home were not considered or pursued with any
vigour.
• The needs of his mother and how her relationship with her son and
how tensions between them could be helped were not assessed and
considered early enough
Comment
• There was no thorough social history taken of his life.
• The admission in November 2004 was on the balance of probability a
missed opportunity to compulsorily detain him.
consider alternative
medication and monitor its efficacy in a controlled environment.
Previous admissions had little clear purpose apart from that of a
reactive response to his mental state presentation.
• The Risk Assessment documentation available at the time was not
used to its full potential.
Since the 11th September 2001 he
had been treated by the local psychiatric services (referred to
throughout this report as the MHTrust) under the direction of the same
locum consultant psychiatrist and had a diagnosis of paranoid
schizophrenia.
We were however
shocked to learn of the volume of patients he had involvement with
and the amount of domiciliary visits he made in order to respond to
relatives and other professionals concerns.
On 11th November 2002 he was visited at home by his CPN as a result
of concerns raised by his mother. He appeared agitated, deluded and
paranoid.
He talked of a friend controlling his thoughts and life.
According to the CPN notes he spoke about killing this friend and then
all would be well.
He went on to tell the CPN that he had been on a
date some weeks previously
and that he felt he could have raped the
girl and that he felt possessed.
He was admitted informally to hospital
that day.
There is a single note on admission that he felt he could kill
someone.
A positive urine amphetamine test was taken on this
admission
Jo
S
Comment There is curiously little examination in the Report of the efficacay or otherwise of the depot injection.
Was the dosage enough ?
Did symptoms and illness behaviour 'come in' just before the next dose was due
- indicating that the interval or the dosage was not reaching a steady therapeutic benefit.
The mother would have seen, and reported if asked.
It is a key enquiry in depot regimes.
There is a case for taking a blood estimation just before a dose is due.
There is a case to be made for taking a reading when a satisfactory effect on illness behaviour has beeen reached
- so that 'next time' there is the opportunity
to compare current level in doubtful observation, with what was effective for the individual.
This is important where there is history and 'risk'
His mother was the principal observer of his behaviour.
She expressed her view that his care should be through Mental Health Detention
.....
we found the decision by the Approved Social Worker not to make the
application questionable in all the circumstances.
But 'B' was accepted as being informal, despite a history of 'making his own movements' .
He was allowed leave when he was seen as an in-patient to be unwell.
There was no attempt to find a meaningful daily and weekly routine, nor adequately to find an appropriate medication
regime that could be noted for the future as being successful.
It was in his story that obesity was something he did not want. Yet olanzapine was continud despite a gain of 5 stones in one year .
For four years the clinical lead post was a locum consultant.
At an assessment at home, an ASW saw him as floridly ill, yet discounted two medical rcommendations for MHA detention, and accepted he could be admitted informally even though 'B' had indicated if he was going in , it was only for one night. That leaves the decsion aboiut MHA detention to others, in a situation where he might conceal illness.
He has no recollection of the tragedy.
At a clinical appointment kept the same day , the consultation found insufficient indication of illness.
back to Inquiry list
back to Home Page
|
|