Comment and Summary Inquiry Dineen; mhsu

mhsu - the nominative for this patient - misused cannabis form the age of thirteen. He was estranged for his mother's partner. He could not live there .

There were no elder siblings

The working diagnosis was schizophrenia
He never worked. He never settled down.
He gave a good impression of intelligence and social skill
he was seen as manipulative.
He was known to carry knives, and to threaten.
At the final stages he was known to have wandered into different catchment areas.
Consultant advice was to involve the police.

He never maintained medication, which was efficacious.
As an itinerant he may not have had enough continuity nor GP contact to do this

His mother was a constant accessible, always available, and kept in touch when she could - in the final days finding him lodgings and trying to obtain intervention.

She had never been given contact advice, and the limitations of that, so as to turn to other plans, if the first one did not work .
She seems not to have been registered as an important contact, an updating observer, and source of influence and support to mhsu.
She was not turned to by the professional services in the final two months which the Panel concentrated upon.

The circumstances of the final tragedy were those of florid illness behaviour
The final contact with his presentation at a Unit was dealt with inflexibly, and without enough identification with circumstances and history of mhsu.
There was no attempt to contact nor to inform his mother.

Hindsight reflection by the consultant at the Unit was that itinerants need to be attended to differently.

The issue was MHSU asking for medication !

MHSU declined to give access to his case notes