A Sm. was aged two when adopted into the family created when his step father married his mother . His biological father had left home before he was born . He lived in the family home with his step-father and his mother , his younger step- brother and step-sister . The events occurred there . Looking back it seems he began to withdraw from his family during teen-age . He did not succeed in developing his own line in life . It is likely his adolescent friends , with whom he went to football matches and spent time with , occasionally trying street drugs , were told by him of 'voices' , something his family did not know about and that he was 'against ' his mother . His time with the territorial Army exposed no difficulties , but he never succeeded in staying in one job . He is described as withdrawing to his own room at home , and as spending more time 'on his own' ,walking , running , and cycling - and on one occasion was attacked by a bunch of youths , after which he carried protective defence .
Between sixteen and twenty four years of age he held a succession of largely labouring jobs , the longest lasting sixteen months .
There was some family pressure to leave home .
Aged twenty-two his family doctor thought a complaint of tachycardia , indicated an anxiety problem , and referred him to a counsellor service used by the practice.
The counselling continued for a year , up until his admission , and resumed immediately afterwards . There seems to have been no accounting of what went on , nor what was disclosed at the sessions , and no discussion of any outcome or progress with the family doctor who referred , although both the counsellor and his supervisor were based at the medical centre where the family doctors practiced . Nor was the Inquiry panel able to obtain any response from the counsellor.
A year later , he told his family doctor that he 'heard voices' .
This led to an OP appointment which he attended alone although advised to have a family member or friend with him .There he accepted advice that he should be in hospital and arrived there alone .
It is likely the aftercare community nurse team were told of the admission circumstances at this time . In hospital he seems not to have been allocated a named nurse until late in the care . The Inquiry describes a review meeting as multi-disciplinary composed of psychiatry , nursing staff but not the named nurse, occupational therapy although he never went to that department ; no social worker assessment of the social background was sought.That meeting foresaw the possibility that his admission consent to be in hospital might be withdrawn and that a detaining Order might then be applied .
The definite diagnosis was schizophrenia .
His response to medication , discussed at a weekly ward meeting , which his named nurse did not need to attend , got him home leave on his first week-end . He went home on his own . His parents visited the wards on most evenings during the first week , signing in with staff , but were otherwise not interviewed by staff . On his return he mentioned he had not got on well with his mother , and would discuss this with the consultant .
His reluctance to accept oral medication led to a second line of treatment being prepared so that he had a ward test dose of a depot medication . His father , anticipating the early discharge of A Sm. , talked with the consultant and expressed his concern for after discharge , pointing out the number of 'weapons' still at home ; and that the father had found small quantities of tablet medication at home . There were difficulties at home with
A Sm. upsetting the family ways .
The decision was made to continue pre-discharge preparation and A Sm. was called in to the interview , and challenged about missing medication ( sulpiride ) , but because tension arose , the question of weapons was not raised .
The intention to discharge was postponed and replaced by trial home leave for a week , after which , all being well , he would return for a depot injection and be discharged to community nurse team for future depot injections after care , and a follow-up out-patient appointment with the consultant . There is no note in the Inquiry that anyone visited the home during this period at home .
He had given no trouble in hospital ; although in retrospect he was not always there , not subject to a daily programme and often being off on his own into town , and to his home , without the ward knowing . The Inquiry notes his named nurse and ASm. could only have been in hospital together on five days .
ASm. was classified for a level 1. Care programme approach, his aftercare rating being at the level of out-patient supervision .
The inquiry is critical of this level of involvement after discharge , pointing to the little opportunity to test his improvement with challenge in close observation , during a very short stay in hospital , in a first presenting serious illness . The Inquiry remarks on his failure to take tablet medication at home ; his unhealthy possession of weapons .
The ward had been reassured by his reclaiming his job . But this was lost within days .
The Inquiry finds the absence of contact with the family unfortunate , and questions the current importance given to 'confidentiality ' .
The need to respect the fact that A Sm. was adult , meant his parent carers , with whom he lived , upon whom he depended , were insufficently listened to .
The serious criticism the Inquiry makes is the lack of involvement from social work . Although the LA Social Services Department placed social workers with the community social worker mental health teams , it seems there was little connection with the ward .
The Inquiry felt that schizophrenia is always to be seen as a severe illness , and requires a full care programme with social work involvement in assessment and in preparing aftercare support with family carer involvement in its planning and execution .
The letter of discharge , is a week late . It is a good summary of the hospital papers without pointing up any problems .
A Sm. had left his job on the same day that he started .
A support nurse from the community nurse team - based outside hospital - visited a fortnight after discharge to give the depot injection , which was refused . A letter was sent to the hospital consultant telling of this .
This is the crucial change in circumstance The system then in place did not call for the response of an immediate multi-disciplinary review of aftercare .
The community nurse was chosen partly because he looked after the patients on the list of that family doctor .
A Sm. was hearing voices subdued by the tablet medication , but talked appropriately . The nurse reported the rejection of medication , and the satisfactory level of interview behaviour , to the ward doctor , the consultant office , and to the colleague of the consultant who acted in her absence ; but not to the family doctor .
The following day the nurse wrote in full to the consultant , copying the letter to the GP .
The mother rang the nurse the same day , reporting the son was staying in his room a lot of the time . She asked to see the consultant . She phoned the surgery for an appointment , and was given one for three weeks time .
The community nurse called again a fortnight later, had a friendly talk with ASm . When the mother joined them a rather tense exchange followed. The nurse ended the encounter on that account. It is clear it was known that ASm was not in what ASm would think of as an open and supportive household. The nurse noticed and reported family strain. He phoned the consultant office, and was advised to make an Out-patient appointment for a fortnight hence.
Five days later the tragedy occurred : the mother and half brother were killed at home : A Sm. told the surgery and the police .
Review Wood; Smith (A)
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