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oh, what a fall was there
| Inquiry Brouder ; S North West Surrey Mental Health Partnership NHS Trust youngest of six plus, 2 x half sisters step father . unruly childhood sex and other assaults. Disturbed education some reading; little arithmetic. No qualifications and un-sustained low skill employment with near family. criminal record himself and an elder brother mother said voices but there is no further description, neither expanded, not examined nor recorded . That is a crucial neglect. S was prescribed olanzapine 10mgms – a medication primarily used for schizophrenia management but sometimes for the overactive form of mood illness – hypo-manic behaviour. alc +cannabis from elder brother criminal smashed step pa car involved in several fights and hurting. Mother not supported, eventually had a stroke, could take no more and killed herself. S. kills another drinker in a pub in an argument. He is found unfit to plead – reasons not given, and is sent to a secure Unit for those with learning disability. “A number of recommendations within this report suggest changes to the way carers are treated, to be mindful of their needs independently of the principal focus of care and to ensure that they are fully engaged within the ongoing process of assessment, care and review.” “At various times there is reference to a variety of symptoms and possible psychotic illness but there is no definitive assessment material to hand in the records. He is prescribed anti-psychotic medication but his compliance is variable although this too seems not to have been closely monitored at any point in the care process” The presence of a possible personality disorder is never assessed despite the complicated presentation and behaviours consistent with such diagnoses as well as a reference to autistic spectrum disorder but it was never assessed and seems to have prompted no further action or specialist assessment. The level of learning disability is never fully assessed and this is borne out in the decision by the psychology department to discharge him for failing appointments. He is described as vulnerable and chaotic. It is clear he cannot organise himself and it is known that his literacy and numeracy skills are poor. However, there is no formal assessment of his functional skills and how this may have impacted on need and risk. Here the panel encountered a confused picture in which a referral was made, the initial referral was referred on in the department, relegated to a trainee and ultimately did not generate a product consistent with the original request. In fact the failure of Mr S to comply with appointment requests resulted in discharge from the psychology service without him ever being seen. Further attempts by the probation services to secure access to the serviceby actually accompanying Mr S to the appointment were interpreted by the psychology service as a potential breach of his human rights. This scenario implies a highly defensive practice which may not have served the best interest of the patient and may not survive the professional peer test of reason. There is overwhelming evidence within this case that non-compliance was a recurrent theme. Despite the evidence those involved in the care of Mr S did not act decisively to gain control and establish a regime in which confidence of medication compliance could be achieved. Whilst the use of the Mental Health Act was considered, there is no convincing evidence in the records that an admission to hospital was really given serious consideration. Social Services were advised that Mr S was a vulnerable adult in October 2002 following the investigation into assaults against his sister under Child Protection Procedures. Nevertheless there were no proceedings instituted under the department's Vulnerable Adults Policy. This would have prompted a multi-agency case conference, formalised care planning The evidence gained in the course of the inquiry is that those involved acted within a knowledge base which might at times have been below the expectations of a reasonable well informed and reasonably educated system. What the evidence does imply is that overall those involved in the care of Mr S failed to individually or collectively stand back and appraise the situation with an informed overview. This has raised significant concerns regarding their overall supervision and ongoing education Where a person does not have the capacity to make a particular decision it is then a matter for the professionals to decide what would be in his best interests and act accordingly. S is able to read to a “ reasonable” degree. He is reported to have difficulty in managing money. Nevertheless he is charged in possession of crack cocaine, heroin, and amphetamine The fact that Mr S's mother was made responsible for his medication suggests that he was deemed unable to understand the reason for its prescription and unable to organise himself to take it. It is significant however that, following the homicide, he was deemed unfit to plead. Clearly there were differing views on capacity in this case which were used as the basis for decision making which ultimately do not stand up to scrutiny Following the onset of her poor physical health, Mr S’s mother developed a history of anxiety and depression. She died in June 2005 after driving her car at high speed into the Thames at Walton Bridge. Mr S is described as vulnerable and chaotic. It is clear he cannot organise himself and it was known he cannot read or write. However, there was no formal assessment of his functional skills and how this may impact on need and risk. At no time in the sequence of care did all agencies achieve a meeting where all appropriate interests were present or served. There is no reference to a differential diagnosis. At various times there was reference to a variety of symptoms and possible psychotic illness. He was prescribed anti-psychotic medication but his compliance was variable. There are a number of factors which were only acknowledged or given passing comment without follow up action. For example the impact of illicit drugs is referred to but never evaluated. The presence of a possible personality disorder was never assessed although it is clearly at the fore of thinking. The community nurse referred to a recollection of a reference to autistic spectrum disorder but it was never assessed. The level of his learning disability was never fully assessed and when the option availed itself he was discharged by the psychologist for failing appointments. Mr S is described as vulnerable and chaotic. It is clear he cannot organise himself and it was known he cannot read or write. However, there was no formal assessment of his functional skills and how this may impact on need and risk. There is little evidence of integrated thinking between services. ?POVA? There were no multi-agency meetings which would have enabled a holistic review of his difficulties. This position prevailed throughout his care despite the involvement of the police, probation, mental health, learning disability, Social Care and primary care services Mr S’s mother had had a stroke, a perforated ulcer and periods in hospital. She had become depressed and suicidal and lost her job. It was also noted that she had a lot on her plate with six children, Mr S, his relationship with his stepfather and the fact that one of her other son's was associated with both drugs and crime. There is a consistent picture of a highly burdened person with serious health care problems who is expected to take the lead carer role for a very complex and challenging individual. Mr S's admission to hospital was considered but the violence was not seen as significant and he was being managed by his mother. Despite all of the above it is clear from events that the professionals involved in delivering care took the view that Mr S’s mother was able to carry on taking the lead in caring for her son. This was reinforced when in July 2003 Mr S and his mother are seen by the ACPLD. He impressed on her the need to ensure Mr S took his medication or face the prospect of him ending up in a secure setting in which care could be delivered.
By October 2003 when there was still no response from the referral to
Social Services, the ACPLD, who was not familiar with CPA, reluctantly
took on the role of care co-ordinator and arranged a CPA meeting. It was
attended by a senior care manager and the ACPLD assumed a
community care assessment and carers assessment would be done. Mr S’s mother was made responsible for his supervision and care because there was nobody else. There was no consideration of whether it was acceptable or appropriate. The community nurse picked up the case at this stage and reputedly started a nursing assessment with a view to organising respite care. Records show one meeting with Mr S and his mother at the Outpatient’s clinic and one at home in September 2003 but there was no additional recorded discussion with Mr S’s mother or reference to assessment of the carers needs or discussion with her. Difficult otherwise than to conclude that nobody cared enough to intervene and sieze charge. Better to let things go, and hope they landed somewhere else No reference to assessment of the carers needs or discussion with her. A Sec 2 [ MHAct} would have been right as assessment outside was not going to be possible etc etc etc etc .
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