M ental I llness C oncerns A ll	Inquiry Gunn: Pick Event September 2002. Inquiry Report January 2005 Pick chased his victim down an alley amd killed him stabbing him several times. He had been discharged from a mental illness admission ward, a week earlier, without a substantial diagnosis, with a plan for aftercare visiting and medication as for schizophrenia.. He was seen at home by a community nurse the day before the tragedy. He had epilepsy since childhood. [ a kind of schizophrenia is associated with a previous epilepsy some years previously ] He did not complete an irregular education. After a short time in labouring jobs he remained unemployed. He did marry. He was known to carry on in drug abuse of various kinds, including amphetamine and alcohol. He developed symptoms of schizophrenia. Dale's last admission commenced onm 10 july 2002. As previously, an informal admission, it followed recorded concers in the community about the voices that he was hearing telling him to hurt others, and concerns about his carrying a knife. Some of these referred to having to kill his mother's partner,and were accusatory of his wife. There were concerns in the community about a possible relapse, and about the community teams' inability to stabilise his mental health. The locum consultant in post for a year, in charge held to the different diagnosis of personality disordee with drug abuse inducing psychotic states. His post ended five days before the tragedy A temporary staff psychiatrist earlier posted all the diagnostic symptoms of schizophrenai and suggested clozapine, because earlier depot medication and oral olanzapine treatment had not subdued the command delusions. The Inquiry returns to this suggestion, whilst accepting that Pick was often non compliant. The inquiry does not indicate how it was the previous anti-psychotic medications failed . His condition is referred to as treatment resistent It describes neither dosages nor duration of treatment. Clozapine requires close contact and agreement for blood examinations,and does revive epilepsy. An angry threat of assault on a nurse whist he was an informal in-patient had led to a proposed MHAct detaianing Order. Assembling the necessary opinons was delayed and Pick absconded for a day returning and then seemed to settle, so that the incident and the proposed section were left in the past. In his last month before the tragedy, Pick seems to have behaved acceptably on the ward, and indeed, was much away from it on leave, without incident. Forensic Unit opinion was requested but could indicate nothing more than what the current area mental health team could provide as aftercare. He was not 'detainable at that time. The Forensic Unit was being led by a locum consultant [ ironically a rehabilitation consultant - what Pick needed ] with little forensic experience or training being there, largely 'to keep things going', with a locum staff doctor. Five different community nurses had visited during the previous two years. The in-patient ward relevant to the catchment area had only locum consultant psychiatrists over the previous five years The in-patient admission ward was overcrowded, understaffed, staffed with agency nursing, had a rapid throughput, was tense and edgy, without confident leadership, the conditions being somewhat anarchic. Pick was known to carry a knife. He had been previously aggressive, and had uttere threats, had offerd a knife in frightening circumstances. The Panel Report is hardly inspired. It returns agaain and again to the possibility of an MHAct Section, but does not say how that could have been concluded, by whom, or when, or for how long, when his ward behaviour settled after the one incident. It returns to the suggestion that clozapine might have been tried and succeeded. But there would have been difficulties in it's use. It has discovered a hard pressed workforce with no very settled leadership What it does not say is how Pick could have been sectioned, where he could have been detained safely, within even a perfect mental health service, without a policy of preventative detention in a Secure Unit; and tghe point of detention when there is no aftercare meaningful rehabilitation activities in place. Comment back to Inquiry List back to Home page.         E-mail reaction is welcome mica@didgy.freeserve.co.uk