Following the incident, the Trust carried out an internal review using root cause analysis. The review was neither timely nor thorough. 1997 Reactive depression (some suicidal ideation referred to Psych OPD) ?? alcohol abuse / poor diet / anxiety symptoms 1.Early 1996 parents split up. 2. Split up with girlfriend ‘Mid 1996 3. Lost job ‘middle 1996’ 4. In prison for motoring offences ‘association with alcohol’. Living with father no communication feels father always nags him etc. Parents recently separated. Client has poor relationship with father and his partner. Good relationship with sister and mother. Hopes to go and live with mother when she finds appropriate accommodation. Qualified in landscape gardening although presently unemployed. Keeps in contact with a number of friends although quite anxious when out with them in pubs. Finds he starts to feel paranoid and on occasions leaves his friends and goes home. History of drugs misuse (Hash, LSD) Now drinks to excess, but no drugs. Says that drugs cause him to feel paranoid and he tries to avoid this feeling. Wants to be able to go out socially without feeling overly anxious. The offences were for alcohol related motoring offences. It is stated that he was given an eight week prison sentence and six driving licence penalty points. Consultant to GP 1997 .... ... [patient B] admitted to drinking to excess for many years, spending up to £200 a day on drink and related matters, not surprisingly getting into debt. I hear his mother is now bailing him out. While inside, he found out that he had felt a lot better without excessive drinking and therefore these days seldom exceeds 4 pints in 1 session. [patient B] also admitted to taking amphetamines, LSD, cocaine, cannabis and ecstasy since when he was about 16 I would recommend starting him on Citalopram 20 mg in the morning and I am arranging for him to be reviewed at my outpatient clinic in about 3 months’ time. In the meanwhile I understand he is already being seen by the CPN, who will no doubt get in touch with me if there are any problems’. Feb 2002. GP... Unfortunately, he has now returned with a long list of problems. He has started drinking again, drinking around two bottles of Vodka per week, his girlfriend of one year has left him, he has relationship problems with his mother and step-father who he lives with, he has been having increasingly angry outbursts, is unable to sleep and he has also talked about a pain inside which he cannot cope with anymore’. He has been having suicidal thoughts for 12 months now and regularly thinks about jumping off bridges or throwing himself in front of a train. The day before yesterday, he in fact, stepped out in front of a car, which swerved narrowly missing him. Although he had not made any particular plans to do this and had not written a note, he wishes the car had hit him and is still contemplating further suicidal acts. On 21 May 2002 staff at the Ravensleigh Resource Centre wrote to the consultant psychiatrist: ‘Thank you for referring the above to our service. Unfortunately he did not attend his appointment and has not responded to letters asking him to contact us. Therefore he has been discharged unseen.’ . The intended detoxification treatment did not take place. Sept 2004 GP ... Thank you for seeing this chap who came accompanied by his mother to see me today. He was referred to your service in February 2002 by Dr Cameron, my partner, as an urgent referral. At that time, he was depressed and also drinking excessively. He had several appointments sent to him but in fact I believe never saw yourselves, since he defaulted all his appointments. He has subsequently had several fits and the diagnosis was made of epilepsy rather than alcohol withdrawal fits. He has not been on anti-epileptic medication until I saw him today, since he had not collected prescriptions beyond the first repeat. I started him on Epilim 200 mgs tds today’.< > His mother, who did most of the talking during the consultation, described a situation where be had been increasingly reclusive, latterly spending most of his time in his bedroom. He had become increasingly apathetic, walked out of his job as a landscaper some 3 months ago after 4?? years in the same job. He had also “packed his girlfriend in”. He still sees her, however, from time to time. His mother’s description of the situation was ‘had a lovely girlfriend but can’t be bothered. Increasing apathy, lack of interest in everyday things, even difficulty getting out of bed or making a cup of coffee, is the principal presentation of his problem. His bedroom had become reduced to such a state that currently, the contents have been transferred to a skip by his mother and sister. He suffers with poor sleep but denies any particular suicidal ideation. His manner was not that of someone severely depressed in my opinion. He did not avoid eye contact, he did not show evidence of psychomotor retardation in his speech or body posture. His descriptions of recent life events were, if anything, rather matter of fact. He does not appear to have been weepy or guilty about recent events . I was not sure about the extent of depression here but felt it more appropriate to seek a second opinion. In the interim, I have started him on the drug he was on previously, Paroxetine at 20 mgs daily and I am due to review him in some 3 weeks. I enquired regarding his current alcohol consumption and it would appear, mainly due to financial constraint, he has cut down on his alcohol consumption. At this point it was the clear impression of the GP that the referral to the consultant psychiatrist by his partner in September 2004 had yet to result in an appointment. He thought that an additional letter to the consultant would add further clarity to consideration of the current clinical situation.< > For that reason he wrote to the psychiatrist two days later as follows: ‘15 April 2005 This 29 year old man has recently been in contact with the Crisis team who have in turn liaised with yourself When he was seen by the Charge Nurse last month, it appeared that his problems all seemed to be related to alcohol (8-12 pints of strong cider per day) and recreational drug use (Cocaine £120 per week). Saw him 2 weeks following this contact when his main problems seemed to be his continuing epileptic fits and he was having I per week and he felt that this was having the most significant affect on his mood, which he described as being ‘up and down’. I challenged him with regard to his alcohol and cocaine use and he said that he had been drinking heavily for a long time, stating that he now only drinks socially around 3 times per week. With regard to his cocaine habit, he states that this is also in the past and he hasn’t used anything for months . I therefore increased his Epilim and then agreed to review him in 2 weeks. This week he has attended with his mother who remains extremely concerned about him. He continues to have fluctuating mood swings and at times she is quite frightened by him. He is often disorientated in time and doesn’t know whether it is day or night, let alone what day is. He has displayed some bizarre behaviour, including taping his door up with duck tape in order to keep people out. There are other days when she describes his behaviour as normal, but these only occur on average, 2 out of every 7. Both he and his mother seem to think you are planning to see him again, though this was not clear in the letter we received from the Crisis Team Charge Nurse. I would, however, be grateful if you could see him in the near future.’ Nobody takes charge of patient D's mental health problems. The downgrading of the consultant position allowed decisive leadership to lapse. There was no continuity in addressing the many concerns and observation put by his mother, to various representatives of the secondary mental health services. Her attempts to convey an urgency in what she saw, got lost. Even this Inquiry Report manages to downplay her urgent information, saying that ... she only wanted an appointment with an authority in the service. 20 April 2005. Discussed in referral meeting on 20 April. Referred to Way Ahead. Letter sent to GP’ Both the CMHT Team Leader and the consultant’s secretary had intended to write to the GP to inform him of the referral. In the event neither did so and the GP remained unaware that the referral to Way Ahead had been made until he was interviewed as part of the Independent Inquiry. He had previously been interviewed as part of the internal review process. The GP was well aware of the services offered by Way Ahead and had previously referred patients for those services. He stated to the Independent Inquiry that he would have also done so with patient B had that been the most pressing consideration. However, he was of the opinion that his patient required examination and assessment by a consultant psychiatrist; hence the referral to the CMHT. The initial letter from the GP was addressed to the consultant. But the Trust policy, defending itself by quoting the policy 'New Ways of Working' now, was that all such requests would go first to be received by the team and then allocated as they thought fit.< > Once the option of restrictive admission is not on offer, indeed never attempted, there was no management in force for sufficient intervention. ‘Following referral to A&E department on 16.03.05 by yourself, for mental health assessment; I assessed [patient B] and also had the opportunity to speak to his mother. [patient B] stated that he is upset and frustrated with having frequent fits. He said he has had 4 epileptic fits in the previous 4 days. He showed me a bite mark on his tongue which he said he sustained during a fit. [patient B] also said the injury on his arm (for which he received A&E treatment earlier that day) was also an injury sustained during an epileptic fit. He said, ‘people keep telling me I am depressed but I do not feel depressed”, [patient B] certainly presented as elated, in a nice way, and he was well focused on the account he was giving me. He maintained good eye contact and certainly did not present as depressed. He was sober, coherent and rational at the time. “I have not tried to commit suicide; don’t let anybody tell you otherwise”, he said. He denied having suicidal/self-harm ideas. [patient B] said he is drinking a lot (i.e. 8 - 12 pints of ‘strong cider/day). He said the drinking helps him get rid of the boredom. [patient B] revealed to me that neither his mother nor his G.P. is aware that he uses cocaine. He said he is on £120 per week habit. He went on to say he sees alcohol as a problem, not cocaine. I tried to gently educate him on the probable impact of cocaine on his behaviour pattern but he was having none of that. He said he has been using drugs for a few years and if cocaine ever becomes a problem, he would stop using it there and then. Towards the end of the assessment I invited [patient B]’s mother to join us in the assessment room. She said she believed [patient B] was depressed and also expressed concern at [patient B]‘s changeable behaviour. He apparently can swing his behaviour from being calm and gentlemanly to being agitated and at times looking very depressed. Unbeknown to [patient B]’s mother, the behaviour/mood pattern she described is typical of that of a drug user. The cocaine will give him periods when he feels high and agitated. Then when the drug wears out of his body system, his mood drops to a low when sometimes drug users feel suicidal. It is all part and parcel of the illicit drug use package.< > I discussed this assessment with our Consultant Psychiatrist and he did say it is possible the impact of cocaine on the central nervous system is exacerbating the frequency of epileptic fits. There is not a lot our mental health services can offer [patient B] until such time he shows a readiness to get the drugs and alcohol problems sorted. He refused help with his drugs and alcoholic problems. Plan: Discharge him home. Please note that [patient B] authorised me to discuss the drugs issue with you but he still does NOT want the drugs use information passed on to his mother. Charge Nurse Crisis and Home Treatment Team<> he has attended with his mother who remains extremely concerned about him. He continues to have fluctuating mood swings and at times she is quite frightened by him. He is often disorientated in time and doesn’t know whether it is day or night, let alone what day is. He has displayed some bizarre behaviour, including taping his door up with duck tape in order to keep people out. There are other days when she describes his behaviour as normal, but these only occur on average, 2 out of every 7. The Trust staff did not put themselves in the position to exercise clinical judgement and took no action other than to refer patient B to a voluntary sector provider. This was despite the GP referral letter expressly stating that he wanted a consultant opinion about his patient. On 18 May, patient B attended his GP with his mother. The entry states: ‘?due psych referral ?? paranoid – not sleeping. Convinced friend trying to break into house. Running and in garden with knives. Given sister’s sleeping tablets ?? I 70. The GP suggested to his mother that she pursue this directly with the consultant. This was the last contact with the GP. 71. Patient B’s mother informed the Independent Inquiry that she telephoned the consultant’s secretary on a number of occasions to chase up the appointment with the consultant. Her son was reluctant to attend the hospital because he perceived that there was a stigma attached to his mental illness. For this reason she thought that the consultant would visit patient B at home. That recollection is shared by patient B and by his sister. That level of response was not for her to make the decision about. She did her job by trying to explain the seriousness of what she saw her son exhibiting. How was she to know that the professional response was lacking in the ability to see any urgency. 72. His sister informed the Independent Inquiry that she had telephoned the Priestley Unit one weekend during this period and offered to bring her brother to the unit. He was willing to be admitted as an informal patient. She was apparently told that access to the service would have to be via the consultant. At interview by the Independent Inquiry, patient B’s mother stated that the reason for contacting the consultant’s secretary was that she was exasperated with the lack of progress towards an appointment, None of the secretaries, or the consultant was able to recall these conversations or arrangements. There are no written records retained. The Independent Inquiry has no reason to doubt the sincerity of the recollections of events by the patient, his mother and sister. Patient B’s mother is clear that she was expecting the visit on 2 June 2005. The records management guidance: NHS code of practice, Parts 1 and 2 , became effective from 5 April 2006. Although diaries are not specifically mentioned, the guidance does refer to day books and recommends the period for retention should be two years after the calendar year to which the book refers. Recommendation: The Trust should develop and implement a policy for the safe retention of records, including diary and message books. On 3 June 2005, patient B was arrested for the murder of his step-father at the family home. The sentence was reduced to manslaughter upon provocation No evidence of mental illness was put before the Court It is the opinion of the Independent Inquiry that the treatment offered to patient B towards the end of the period reviewed fell short of that which should have been expected for the condition he was presenting at that time. The Trust staff did not put themselves in the position to exercise clinical judgement and took no action other than to refer patient B to a voluntary sector provider. This was despite the GP referral letter expressly stating that he wanted a consultant opinion about his patient. [ The voluntary body ] ... Way Ahead subsequently closed the case, as far as their alcohol service was concerned, but did not inform either the GP or Trust at that time. The failure by the CMHT to inform the GP of the referral to Way Ahead contributed to his understanding that an outpatient appointment for his patient was still awaited in May 2005.