Two people from ethnic minority backgrounds are dealt with together, because they are both in contact with the same area mental health service
They are both badly dealt with by the Teams, and by this Report.
There is a reference to a longer report but no link is given. There is no account of the final offence by S1.
S1 is of a jamaican/white relationship. He has three or four convictions - offence against a person, and against property
Since aged 13, he has been in contact with mental health srvices. There are five admissions averaging 6 mths, and for each he is transferred to medium or low swecurity Units for aggressive behaviour , presumably to staff.| That does not get him on any kind of risk assessment or review for risk. Despite the periods of long admissions he never gets an authoritative lead diagnosis.
It proceeds from 'drugs' to schizophrenia, but finally and thereafter to bipolar. His treatment is lithium and olanzapine. It seems likely he did not collect this during the eight weeks prior to the tragedy. S1 killed the last girl friend late in the May, shortly after he had requested an Out patient appointment. She had been an inpatient but her admission did not overlap with his in-patient care.
Care co-ordination is difficult, because not wanted, or because it takes place on or from the doorstep. S1 is often asleep before the afternoon. He associates with a girl friend ( a minor ) who becomes pregnant. That relationship ends after 5 months.
There is reference to a girl friend being imprisoned by S1.
There is another girl friend who is seen at A & E for head injury.
The care co-ordinator does not know of these relationships. S1 doesn't want information about him to be shared with his mother, but the Co-ordinator keeps in touch and helps.
It is not said that the mother feeds inm or is asked for, her observation and experience of S1. Six months before the tragedy he is on a Sec 3 Order which is allowed to expire. Three months later he still does not have a definite lead consultant. There is no account of an aftercare plan or a review date. The CPA is missing. Staff are not available fro a variety of reasons.
S2.
is a Somalian gentleman, fluent in English, and well known in the local Somali subculture. He helps out in that community, and at the local Citizens Advice Bureau. He has three realively minor convictions.
He is admitted in November 2002 because he had become violent at home smashing furniture, and the television, claiming command voices told him what to do, and that sky TV was invading people's minds using infra red.(!)
He had burnt down the door to his brother's flat. He went AWOL from the ward several times and had violent outbursts there. The staff had no clear lead diagnosis to go by. The clinical lead did not make that definite, or point to it, to be borne in mind in case of failing medication; nor of the risk of a resumption of illness plus aggression.The staff took the view, wrongly, that it was all down to misuse of drugs - khat,cannabis and alcohol. He was discharged after the Order ran out.
Contact with aftercare failed, mostly resorting to telephoning without success.
The somali subculture, followed by the brother, is that you care for yourself and family within the guidance of the habit of the sub-culture
Very shortly after discharge he is paranoid and belligerent, wanting to kiss his co-ordinator, and a Housing Officer. He will target a somali police. Several days of very loud music annoying the neighbours do not allow an intervention.
He is charged by the police for the previous damage.
A court liaison service find nothing wrong.
Soon after S2 expires he is seen assaulting - in front of a Housing Officer - the parents of the eventual victim. He is taken into custody and is seen there by a police surgeon. They are unable to contact mental health for information. No computer records are available.
The same month he boards up all but one of his windows, and writes on an unopened social worker letter s 'every last drop of blood is political'
Early the next month he sets fire to the home of another Somali. A child is hurt, but her mother dies.
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