M ental I llness C oncerns A ll	Seven years after the tragedy this thin Report appears with an apology from the chair , saying any delay is his fault, but no explanation. No blame is to be attached to the local Authority. [ 'The long delay in the issue of this report is regretted by the Panel, the Chairman accepting full responsibility for this.' ] His fellow members on the Panel are from the same home Authority. Elsewhere he quotes this from ... It will be recalled that the 'Safer services; Report of the National Confidential Inquiry into Suicide and Homicide by people with Mental Illness ... made a number of Recommendations .... Amongst others it recommends that individual local Inquiries into homicides be discontinued as they perpetrate a 'climate of blame'. The KB had a solid woking life until he developed an unexplained state of unease and sleeplessness in middle life in April 1997. he is prescribed a hypnotic. Six weeks later in May the GP partner prescribed Propranolol, valium and referred him to the local mental health community team, suggesting cognitive behaviour therpy the introductory referral document is revealed. Neither is the composition, nor the working practice, of this team ever stated. The team is managed by a non clinical lead. KB is accepted and assessed two weeks later, as being anxious and sleep distrubed with mild depression, allocated to a community nurse as his patient, and he embarks on some kind of anxiety management on relaxation, and discussion on cognitive behaviour guidelines without any clinical supervision. How he is qualified to make this level of decision is not clear. The team manager does emphasise to the GP that the responsibility for the patient remains with him. That must mean that no psychiatric doctor is involved at this stage. After nine visits the nurse refers back to the GP for a prescription of anti-depressants. Four months later he is visited by a different community nurse, who decides he is worsening A fortnight later, he is referred - by the team lead - to a locum consultant psychiatrist, who recommended an increase in the dosage of the the mild sedative tri-cyclic anti-depressant, started by the GP at an introductory dosage. What is written to the family doctor is not stated. The Inquiry report says no offer of hospital admission was mad nor was suicidal thought revea Through December he was noted as improved Community nurse visits continue but are not recorded. Four weeks later. KB kills his wife and himself. An immediate internal incident report is prepared but an internal review not undertaken in the knowledge that an External Inquiry would follow. This external Inquiry does not comment on what occurred at the Cotroner Inquest. Police did not find any tablets at the hiouse and they are sure they would have seen them The Inquiry Report says nothing about looking to see whether KB had collected a sufficient prescription, or whether he would have known not to stop them and the danger of thatt. The consultant recommendation was that the anti-depressant prescription should continue for a year. A sudden return into depression would have followed any premature stopping to take medictaion or not renewing the rescription. A sister states that KB had asked to be in hospital, even that he would have paid for this. Other than that there is nothing here to see if she knew of any advice about the medication, and what was the attitude to KB of taking it and continuing it. KB had complained of 'constipation' to the Consultant - a known accompaniment of taking tri-cyclic anti-depressant medication, so certainly KB was taking the earlier smaller dosage. one week before the targedy KB and his wife see the GP partner who prescribed 3mgms of valium to be used when desperate. There is no reference to the anti-depressant medication, continuing or having stopped. The Inquiry report states inconclusions ...that no such care plan existed ... and, a lack of systematic recording beteeen memebers of the team or betwen team and GO's. . some notes were written up well after the visits and once incorrect .. indicating unsupervision and overcasual, doubtless due to cse-load pressure. Recommend CPN recording be reviewd and auditing of them occurs on a regular basis. Home Page Comment   back to Inquiry Link page       E-mail reaction is welcome mica@didgy.freeserve.co.uk