M I C A	Inquests and Tragedies family carer's rights the European Court on family carers in tragedies as 'victims with rights' a grievance redress information site   Homicide Inquiry: chair Mackay; subject X. Mackay is described as a Health Consultant which is maladroit and uninformative.   X. was, at the last four years, in Cornwall, having taken retirement at fifty-nine from his university post, lecturing in statistics in which he was well qualified . A younger brother died amongst a car accident. He is said to have suffered from schizophrenia, but his clinical notes are not mentioned. He married aged twenty-four; his wife, the eventual victim, is not given any background. They had previously spent family holidays in Cornwall which their three daughters, now grown and away from home, remembered in happiness The retired couple had difficulty, moving four times mostly for the wife, eventually finding a home that pleased them. The wife was unlucky in her health, needing a mastectomy, and fracturing a wrist after a fall and was found to have osteoporosis., which restricted her. X also had health problems - an ill circumscribed stomach complaint, which showed up as oesophageal reflux and after a bleed was subsequently treated with Losec., the anti hydrogen ion neutraliser, with reasonable success. But X remained sometimes pre-occupied with this complaint. He presented to the local psychiatric service after a prolonged, dangerous and serious injurious self harm towards killing himself, requiring surgical response. There were prodromal signs that depression was building. He was seen by a visiting junior psychiatrist at the general hospital and then by the consultant liaison psychiatrist who found him seriously ill with depression, informed him that relief from and treatment for this might take some months; ECT treatment might be necesary. These observations seem not to have gone with him when he was subsequently transferred to the local Psychiatric admission Unit; the first of three short [ ten days or so ] admissions, over three months. The Unit was inadequate for it's purpose, examining and recording for illness behaviour: collating and looking out for independent observations from elsewhere ; overcrowded conditions, mixed cases in gender and diagnosis, and in degrees of constraint and urgency; understaffed, with agency reliefs; and with a nursing shift and handover system under constant strain. It was not a pleasant setting for purposeful observation, refelective appraisal, good moral, teamwork and supportive companionship. Nor for achieving continuity in purpose. Four consultants used the same facitlities. It's not clear whether they saw patients on their own in their own offices, or separate interview rooms. As with most Homicide Inquiries the basic working conditions and practices of running the particular case are not outlined sufficently. Senior supervision was difficult, and training and occupational activities had given way to the more urgent needs of getting through the day. The Unit was up for replacement in a strategy developed in 1996, but commissioning vacillation and underfunding delayed a replacement for eight years. [ And then was made with a commissioning error of judgment over the bed numbers that would be needed. It resulted in bed numbers that meant the Unit would eventually start with 100% occupancy - no doubt a managerial dream of efficiency - but a psychiatric care nightmare. ] Bed occupancy when X was an in-patient could amount to over 120%. Even in the replacement new admission Unit at one count twenty patients were 'on leave' although the Unit was 100% bed occupied. The psychiatric service never got a full story; neither from X nor from his wife. In part this is likely to have been because a named nurse system could not be usefully held in place and different nurses therefore saw a part picture only, and never got hold of a patient illness trajectory, or a care plan for ahead. Continuity of observation and a supporting alliance would be very difficult to sustain in these ward conditions. Ward rounds are attended by the Consultant but it is not clear whether X was seen separately. The ward doctor certainly did, and saw the wife as well. On one subsequent outpatient contact X was clearly delusional in depression and nihilistic, incompletely registering what was about him and what was happening. ' Sectionable' in the opinion of the Inquiry panel At other times he declared himself openly, and seemed to be better. That degree of wide fluctuation of level of mood is unusual in the depressive serious illnesses, although a move to relief of some sort is recognised in the evening. It makes diagnosis and predictable level of management difficult Regular morning assessment is necessary. The out-patient presentation raised the possibility that the confusion, and his whole condition, might spring from brain damage in the background The Inquiry Report accepts this was a consideration to be pursued. That would be strengthened if there was memory failure in a time when depression wa absent. Or, evidence of high blood pressure Here it led to putting off a completed working diagnosis for further opinion and investigation. A brain 'scan' was normal, probably the best basis for evidential conclusions. A brain wave record is reported once as normal, but then also as maybe showing early brain damage. SSRI medication for depression, was not working usefully with any consistency. There was not time for other medication to be given sufficient time to show it's worth. X. , at home attempted to strangle his wife. The Inquiry report does not say whether this led to a re-appraisal of risk, and in particular whether this risk was raised with the wife or other family, either during admission or on the one final aftercare home visit. It was known that X and his wife argued and disagreed, that there were recriminations and that X brought up self critical matters from the past, and that his wife was a determined person with her own way of looking at things including medical understanding, and had her own intrusive views about the illness and condition of X. She could be seen as difficult, and thus her views and observations taken with reservation. One daughter was a pharmacist. The daughters were in constant communication with X and their mother. They were not sufficiently approached by the clinical team. Where interviewing is difficult and observation varies in reliability it is essential to find a source that is involved but more detached. The final tragedy occurred at home five days after a discharge from a third admission period. X. stabbed his wife, then reported that to the police. At the police station he was considered fit to be detained but oddly not fit to be interviewed. The Inquiry Report is therefore not able to give any account from X. as to what immediately led up to the tragedy. Nor do they report on his progress at the medium security Unit to which X was sent, without Home Office restriction on discharge, after pleading guilty to manslaughter   Go to Comment Inquiry Mackay; X.	go to the other Cornwall Homicide Inquiries

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