Comment:-Inquiry Mackay; Mr 'D'

Here again a carer family let down by a lack of activity by from so-called community team care, and also by the absence from any serious lead clinical figures, of decision making and lead advice about aftercare intervention.

The family did not know, were not told, how to alert the community team, when they recognised that Mr'D' was deteriorating, and that he was not taking hids medication

The family were not adept in speaking english but this is allthe more reason for taking them through contact arrangements, and makig it easy fro them to do so. The family were immigrant,speaking a form of turko-kurdish, with poor English. The area served has a lot of out-comers. There was no process for getting translators.

Eventually the diagnosis of schizophrenia was entered,
but it arrived after years of shifting clinical lead diagnosis,
the absence of any serious concern, the cover story and cop out diagnosis being that deceptive word 'psychosis'.
So meaningless is this as guidance to those following it,
it becomes difficult for those less experienced to proceed.;
at the very least , there has to be the added warnings – working diagnosis to be schizophrenia.

When that name is underlined, the worry continues, and then fall-back processes are seen as a necessity to be in any Needs Assessment of the CPA Care plan .

That totally failed here

A one-stop centre ERC failed to respond to final frightened visits by the parents, who wanted to input their son's mounting illness behaviour, and who could have added if asked, that he has not had medication for six months.

The family can not be seen as not failing in not getting their message across. How could they know what information to put in, and how serious this illness should be regarded , when the service was so lackadaisical and disinterested, and without alarm.
Similarly the GP was left uninformed, who received no prior indication of what to do, when the family and patient were in trouble with the illness.

A lot of the Report is given to examining the behaviour of a care co-ordinator , for recreating notations, and for not actively getting into this family and the patient.It is easy to criticise the lowest but where was the more qualified lead, who did not reflect upon the malfunctioning of the service they were leading.

Poor supervision and performance management practices ensured poor standards of care went undetected. This was exacerbated by dislocated service design that did not encourage seamless working between internal departments and external agencies.

Again and again this Report, as in ALL the previous 200 Inquiry Reports fails to examine the delivery system properly.

The basis of a team is that it's members meet together often enough to be a team. That means the frequency, the regularity of participants and the content of the together meetings has to be laid out., fore supervisory purpose.

Unless these Reports point out the process failure and highlight the absence of any system in the team as a team failure, the absence of such exposure gives jo indication to managers that they must examine the working practice of the regular behaviour in the teams they assume – just by the name – to be teams, seen to be doing their job.

The team system of meeting has to be attended by managers, enough to know who is there, who is there to lead, and essentially where is the most qualified, the most intelligent, the most experienced player in the team – the consultant psychiatrist ,who is to be there to give the working diagnosis, and to reflect and advise on the consequences of that for the conditions, present in the context and constraints of what is the state of the locality delivery team membership. Too often there appears to be resentment at the importance of that lead 'we are not the handmaidens of the doctor now.

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