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RS had a chequered upbringing , suffering paternal abuse and maternal neglect ,and being taken 'into care' , as happened with some of his five brothers and sisters . The children nevertheless kept using the maternal home as a base until they worked out something else during their late adolescence . The year before his illness became overtly that of schizophrenia , he became a 'born-again 'christian following the example of a brother who had done the same whilst serving a prison sentence , dropping out of previous reckless street society , drug involvement and alcohol misuse , and leaving his marriage . He stayed with his mother , often together with the younger brother , all occupying the one-bedroomed flat . Six months later he presented to the family doctor unkempt , hearing voices and asking to go into hospital . He was accepted as an informal patient . His stay in hospital was not succesful in changing his family circumstances , and his illness was expressed in florid spells outside hospital , three times being returned from irregular leave , by the police , after misbehaving in illness terms by accusing someone without reasonable cause . He was violently upset in hospital on two occasions , restrained and injected with sedative neuroleptic medication . Eventually he was discharged to the flat of his mother , which his younger brother was also sharing , and his care supervised by a community mental health nurse , attached to the family doctor surgery . Depot injections given by her , continued on his fortnightly day at the day hospital . Her notes suggest Rs continued drinking . This admission was for one week and RS returned to live with his mother , on the same weekly depot regime at the day hospital , and with the same follow-up process . RS often appeared 'in control' and seemed well during an OP visit with the Consultant . That he was drinking was noted . He related 'thoughts of harming his mother' to the CPN , at the same time dismissing them . The Inquiry summarises its comments .. " though we have identified individual weaknesses and failings , we believe that the principal failure in this case was essential an organisational one , for which management , both general and clinical , must share responsibility . Resources were too tight and clinical skills were not of the highest standards , but management , from the Trust Board downwards , was ignorant of working conditions and practices at the point where patients who depend on their services meet the professional staff ."
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M
ental
RS was involved in several juvenile offences , often with his brother , and often for food . His schooling was observant , his intelligence at least average , but he left without any examination grades . He had jobs and certainly in one he was respected . He cohabited and married for nine years beteen aged 23 and aged 32 .
He was never the object of a Mental Health Act detaining Order At an initial community interview there a mental health social worker shared an interview and took on 'benefits, accomodation , and family support'. She visited the home many times .
At the day hospital he was seen by a senior in-training psychiatrist who noted the presence of disturbing illness , and on a second visit , in some detail about RS possessing a knife and the thoughts that went with that . The family were recorded as not wanting readmission to hospital , medication was increased , and a fail-safe admission stance retained . Then there was a frightening occasion followed by RS being persuaded to be readmitted , again informally . His younger brother had twice to resist being attacked with a breadknife by RS .
During the last month the younger brother left the flat , although still often visiting . He concluded RS was abnormally drawn to the house knives , and removed them from a customary place , to the bedroom .The CPN shared her feelings of uncertainty with the social worker . The social worker worried that the mother might have to be told , and concerned with confidentiality, discussed this with her senior , but no definite action resulted .
The CPN wrote her concerns to the Consultant , but the letter arrived after the event . RS had killed his mother .