that Consultant Psychiatrists and Care Co-ordinators are aware of their obligations to close relatives to ensure that the latter clearly understand the nature and effect of the patient’s illness.

that it has been a noticeable factor in more than one case of this type that untoward incidents occur in the period following organisational change, whilst the bodies concerned are co-ordinating their policies and procedures and the constituent parts of the new body are “bedding down”.

Social Worker 3 spoke to Mr Field's mother who thought that he had not changed much, though she was concerned with the lack of any activities for him during the day.

The Employment Co-Ordinator then set out her concerns in a letter dated the 28 January 2003 addressed to Social Worker 3 in the following terms: "

The first of them, dated the 28 January 2003, was addressed to Social Worker 3 and it is important to set out its terms in full: "In the light of recent events I felt it might be relevant to forward to you written details of my first and only meeting with Derek. He came to see me on the 21st January and arrived twenty minutes early for his appointment. He waited calmly and patiently until I was able to begin my meeting with him. We spent an hour together during which time I talked through his referral form with him and his reasons for wanting our service. He said he wanted to get out of the house but seemed to be experiencing severe ideations concerning two female neighbours whom he referred to as 'schizophrenics'. He believed that these women had messed with his mind, stolen his soul and his conscience, ruined his life and sapped his strength and energy. He seemed determined to kill them or have them killed. He had found someone who would kill them for a cost of £3000; this seemed to be his long-term goal and motivation for wanting to return to paid work. He seemed to believe the only way he would feel 'normal' again would be if the younger woman were dead, because only then would the soul leave her body and return to him. I made another appointment to see Derek on the 28 January but felt very concerned about his state of mind, as he seemed to lack any insight into his own mental health problems or possible repercussions if he were to carry out his threats. I passed on my concerns to my team leader about the appropriateness of this referral and left a message with your office for you to contact me to discuss the case, and other matters that arose in the interview in more detail.I called you today at 11.55 because Derek was due in at 12 noon and was shocked and saddened to hear of the tragedy that had occurred only the day after he had been in to see me. You are probably aware of these disclosures however they may shed some light on the police investigation."

"In response to your letter dated 30th January I am writing to confirm that I called Sankey House on Tuesday 21st January between 1.15pm and 1.40pm and spoke to a female telephone receptionist."

But, of course, we did not have enough beds so we always had to rely on out-of-area treatment beds and it peaked actually in January 2004." 52.

if an effective CPA meeting had been held in Hospital before Mr Field's discharge, attended by Consultant Psychiatrist 2, a member of the ward nursing staff and a representative of the CHMT (preferably the person appointed or to be appointed as Mr Field's Care Co-ordinator), then it seems to us more likely that the CMHT would have (a) Review of the Care and Treatment Provided for Mr Derek Field Page 2 7 of 42 understood the urgency of Mr Field's case better; (b) given Mr Field an earlier appointment; and (c) been more diligent to ensure that he actually was seen.

Another factor in this case was that there was little (if any) effective contact between the psychiatrists and the CMHT.

It seems to us to be inconsistent that relatives should be encouraged or expected to assume the role of lay carers in many cases, if they cannot be told of the patient's illness and its meaning and implications in everyday terms. 93.

Inexperienced care co-ordinator poor eam reviewing arrangements