This seems a common outcome – a failure to take the illness schizophrenia seriously.

It is compounded by the fact that this service could not attract a permanent consultant.

Standards faltered. Responsibility and authority was ephemeral, was in passing.
Decisive intervention and direction was never sustained. Intentions lacked momentum.

The inpatient ward was overcrowded and overrun, so as to be unlikely to be purposeful except in containment, not in preparing for after-care and authoritative control.

Pick was 35, and living with his mother, the principal observer and witness if called upon for behaviour 'in-between' professional assessments

2 November 2001. This period of admission lasted until 4 December 2001. During this period, there was clear evidence of a range of matters that are centrally important to this Inquiry. There was evidence that:

• he had “thoughts and voices telling him to stab his mother’s partner”;

• he had entered his mother’s bedroom with a knife on four occasions when her partner was there and they were sleeping;

• he was carrying a knife outside the house, because he felt unsafe and thought he might be attacked;

• he was experiencing command auditory hallucinations that were telling him to kill his ‘stepfather’;

• he had derogatory auditory hallucinations in relation to his girlfriend that told him to harm her;

• his alcohol intake had increased, this appears to have been an attempt at self-medication as he said he took it “to silence the voices”

• there was concern about the risk he presented to himself;

• his depot medication was ineffective after the first week.

Add to that the possibility that behind it all is schizophrenia an illness where the patient does not have insight into the illness, and cannot describe an illness history

The professional lead opinion was clouded by indecision about the influence of alcohol and street drugs – the misleading blind alley way often taken by less than fully experienced clinical leads.

Somehow it was decided that some medications for schizophrenia did not work with him, without considering whether or no the ineffectiveness might be that he did not continue with medication outside, and needed help about that.

In hospital environment he behaved reasonably well, giving the impression that the illness was contained and manageable by him, rather than that continuous medication might be the aim to support.

The history of risk behaviour was not given priority as it should have been,

The background, as in all problems in managing schizophrenia, is the difficulty, after temporary responsiveness, in finding and putting in place a life routine which would carry meaning and carry the consent to continue with and make important the taking of medication to maintain the improved living. Rehabilitation outside hospital has fallen away in the funding and commissioning of after-care.

And can be passed on elsewhere, to Social services, charities, and day centres.

Ironically the locum consultant forensic leading that service called to give an opinion was a consultant in rehabilitation. But his forensic service was not thought to be able to offer anything different.

So why bother ?

The mother was always the source for reporting on 'in between' behaviour – but she had to be prepared with ways of giving in her input

Pick killed his stepfather - the details not given

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