JT was long known to be suffering fom schizophrenia. Often accompanied by substance misuse especially amphetamine.
He had been aggressive and threatening in the past
He possessed knives .
He has set fire to his dwelling.
There had been police charge of possessing an axe, a forensic admission and Home Office aftercare supervison.
He was known to relapse if not taking medication. He was known not always to comply with medication.
He was finally placed in a sheltered hostel, where there were other patients on community placements
.
JT was on the list for Assertive outreach.
He asked the consultant psychiatrist in the team to move his medication from depot management to oral medication.
This was agreed without a team review.
The depot medication was reduced ten weeks before the tragedy. Eight weeks before the tragedy it was stopped and oral medication [ olanzapine ] at a low level was introduced.
He was followed up by the consultant and from contacts at the hostel by different team members.
There was evidence if active illness. He was seen to have a knife and to replace one which was mislaid.
He killed a fellow hostel resident - the one who had asked to share a room with him ??
Comment on JT and on assertive outreach
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