M I C A	In 1995 Ms L had a child who lived with Ms L’s mother from infancy; the social services department was involved in arrangements for the child’s continuing care and occasional stays with Ms L and her partner.. However, 4 years later her partner died suddenly. This precipitated a deterioration in her mental health and resulted in an inpatient admission and spending time in a residential setting. • In 2000 Ms L returned home and it was during this period that Mr M met Ms L. At that time and over the rest of that year they grew closer but there were also episodes when Mr M left her and the relationship could be stormy. In November they were reported to be engaged and planning to marry the following January 2001. Ms L was considering going to court to obtain custody of her child, whom she was seeing on a regular basis. • During their relationship Mr M found it increasingly difficult to cope with Ms L as they constantly argued and had problems with some of her old acquaintances. She had become more dependent on Mr M and took to her bed, not wanting him to leave the house. At this time Ms L’s mother, who had a Residency Order for her grandchild, expressed concerns about her daughter having visiting access. • Mr M continued in his pattern of non-attendance for appointments with mental health professionals and Ms L was abusing the use of her sedatives. Additionally, Mr M had on occasions given her more sedatives so that he could leave the house without her knowledge. During this time there was intense engagement with Ms L by the Crisis Response Service (CRS) as she had been threatening suicide. • It was during September 2001 that Mr M made threats to kill someone so he could get some peace. He later took an overdose and was sent to A&E where he was subsequently arrested for threatening and abusive behaviour. On his return home a Carer’s Assessment was planned for Mr M but he refused to co-operate as he felt the assessment questions too intrusive. Independent Mental Health Inquiry into the Care and Treatment of Mr M ------------------------------------------------------------------------------------------------ 7 • Tensions were increasing and during October 2001, after moving to their new home in Netherfield, Ms L attended A&E with a fractured wrist after falling downstairs during the night. Day Hospital was offered and due to Ms L’s ambivalence a gradual programme of attendance with transport was organised. • At the beginning of 2002 Mr M left Ms L but returned a few months later. Again the situation began to deteriorate and home visits by the Social Worker were carried out. The subsequent months saw substantial contact with the mental health services and the Social Worker. • During March 2002 Mr M attempted to crash his car, with just himself in it, and was detained under Section 136 of the Mental Health Act 1983 (MHA). He was later admitted to hospital under Section 2 of the MHA, at that time he expressed thoughts of stabbing his girlfriend. • In April 2002 Mr M was discharged and placed on an Standard Care Programme Approach with an outpatient appointment with the Community Alcohol Team (CAT). Once home the tensions within the household increased between Mr M and Ms L. • During May the tensions in the house were increasing. Ms L attended an outpatient appointment with her Consultant Psychiatrist at which Mr M was also present. Later that month respite was offered at the Sanctuary which she accepted. • There was a review of Ms L’s Enhanced CPA in June, the option of a further stay at the Sanctuary and re-engaging at the day hospital were both discussed but declined. The staff involved with Ms L and Mr M responded to their increased levels of distress by putting in place a programme of home visits and telephone contacts. There were concerns about Ms L’s low mood and reported misuse of her medication and Mr M’s ability to cope with the situation. • On the 18th June the Consultant Psychiatrist and Social Worker visited the house together. Ms L was referred to the day hospital as an urgent case, and a request was made for Mr M to be allocated a Community Psychiatric Nurse. During this visit Mr M was given responsibility for dispensing Ms L’s medication. • In the morning of the 21st June the Social Worker visited the household and saw both Ms L and Mr M. She later phoned Mr M in the afternoon about a possible referral to a carer support agency. Mr M informed her that everything was OK. At approximately 10.00pm that evening Mr M phoned the police to inform them that he had killed Ms L. " However, even had these statements been taken into account it is not possible to reach a conclusion that Mr M was intent on carrying out this killing based on statements made at times of stress over the previous two years or so. Quite a common history in people with difficult personalities in difficult situations, called abnormal pesonalities because they enter into situations of over optimistic companionships, which are too much for them, don't seem to learn from that, the consequnces of their behaviour, keep trying companionships which bring their own problems and then turn to others to adapt to them, until they run out of further options, or don't have them in the first place. Every agency has a go, but it is as if their solutions are only short term, yet hold things, enough to pass them onward to somewhere else, until the parcel drops. They are offered and accept engagements with professionals which they know they do not want. and see as unhelpful. Generally they want - and need - decisions taken from them to clear up a current mess, which removes responsibility from them, and which they can disclaim, a current mess which the professional service does not cope with, not having the relevant resources or the authority to force a resolution or issue; nor are they able to find,create and support, alternative contexts in failing companionship situations. Facing up to consequences is the learning experience, but at this level of disruption only longterm separation from any alternative, from vulnerable people, seems to have any chance; long enough to reopen and redirect them into a different community setting. The old asylums had enough time, enough pacing ability, enough space, and the staff enough generosity of time and optimism coming from that, to work out some arrangement that held the future together, whilst something more permanent evolved. 'M; and Ms L. is a couple in a 'no hope' situation, unable to develop and defend companionship in the face of real problems, and in the case of Ms L, the two of them, M and Ms L- neither they nor the professional teams, could deal with a recurrent serious mood turbulence which lithium [ for manic/depressive illness ] did not resolve for her. 'M' eventually could cope no further and killed Ms L. He pleaded guilty to manslaughter and received a prison sentence We are given no indcation of the trial proceedings, nor of his mental health in the differnt conditions of prison. The list of recommendations and comment back to Inquiry List