Mr 'E' and Mr 'D' had previously shared a ccomodation for three months earlier in thebyear.

Mr E had troubled cearly childhood. His own father cleared off. A stepfather later allegedly abused him. He was referred to the child andadolescence services , attended several treatment sessions both alone and together with other family members during the next six years as a result of re-referrals to the service including a referral in 1995. However in 1996, when Mr E was 14 years old, these sessions were discontinued as he was becoming difficult to engage. [! ] The Department of Child Mental Health finally closed his case in 1997.

He obtained work as a barman in Amersham in 2000 and sometime during this year left home to live in lodgings in the town staying at this accommodation for approximately three years. It is reported that at the end of this period Mr E was asked to leave the lodgings by his landlady as he had 'gone berserk' and that the other residents were 'terrified of him'.

An appointment was arranged for Mr E to see a locum Consultant th Psychiatrist with the CMHT on 8 July. At that appointment Mr E was provisionally diagnosed as suffering from an "acute predominately delusional psychotic disorder". (ICD10 F23.3). The psychiatrist advised an increase in the risperidone to 4 mg at night. A letter sent by the locum Consultant Psychiatrist to Mr E's GP noted that Mr E had a wide range of persecutory delusions and auditory hallucinations. A th further review was arranged for 5 August 2003. Mr E's GP prescribed his risperidone in June, July and September. Nothing was noted for August in the GP records.

There is no record that Mr E attended this outpatient appointment as during the summer he took a temporary job in the Scilly Isles where he st attended the A & E department of the local hospital on 1 October. He presented with abdominal pain and admitted overnight. The admission assessment form recorded that the "the local people had noted inappropriate and strange behaviours". He was discharged from hospital after one night's stay and asked to see his own GP if he had any further problems. It was also reported that he believed a girl was controlling his emotions and feelings.

Mr E is reported to have lived in a tent in local woods for a short period before moving back home with his mother and brother. During this time he believed that "James" was inside his head controlling him.

On 24 March the CPN made a referral to the Assertive Outreach Team after discussing her inability to contact Mr E with his locum Consultant Psychiatrist.

On 5 April Mr E's mother reported to the GP that Mr E was feeling suicidal and a home assessment was arranged for the Crisis Team, but it did not take place as it was not possible to contact Mr E.

On 14 April Mr E's mother accompanied him to his GP as he had smashed up his room, appeared distressed, not eating or sleeping and was smoking cannabis and using alcohol.

A Mental Health Act assessment was arranged for the following day attended by Mr E's GP, the locum Consultant Psychiatrist and an Approved Social Worker. Mr E did not meet the criteria for detention under the Mental Health Act 1983 and he was unwilling to be admitted informally. It was noted that at the time of the assessment he was intoxicated with alcohol.

The CPN made a referral to the Crisis Team but they were unable to establish contact with him throughout the remainder of the month.

Crisis Resolution and Home Treatment
This service provides intensive support to people in their homes during a period of acute illness and is available 24 hours a day, 365 days a year. A main part of the team's role is assessing people with a mental illness for admission as an inpatient, both informally and as a compulsory detention under the Mental Health Act. It was originally set up in 2003 but due to recruitment problems and capacity issues was dissolved and then re-launched at the end of 2004. The service also works closely with the newly reconfigured acute day hospital which provides daytime treatment and support seven days a week to people with a mental illness who would otherwise be admitted Currently there are three properties in the Chiltern district, Mr E's local area, which offer temporary accommodation: A block of 20 self contained bed-sits and flats Two houses of six bedsits each with a shared bathroom and kitchen facilities in each house.

The Crisis Team were unable to meet Mr E as arranged on 6 May as they had another priority but did agree to see him later that evening. It was decided later by the Crisis Team that he did not meet their criteria so they were unable to assess him. The CPN protested at this decision and again the Crisis Team agreed to assess Mr E.

Also on 6 May the CPN received a letter from the Assertive Outreach Team stating that following consideration of the referral made in March, Mr E did not meet their criteria as he had not been disengaging with services for a period of six months or more.

On 23 July the Care Manager recommended that the CPN re-refer Mr E to the Assertive Outreach Team. The Care Manager and the CPN agreed that if Mr E continued to disengage then a case conference th would be arranged.

On the 27 a planned CPA meeting was cancelled th (by Trust) and rescheduled for 10 August 2004.

The Care Manager wrote to Mr E on the 22 June expressing concern about her lack of communication and inability to establish contact with th him.

On 30 June Paradigm Housing contacted the Care Manager as they had concerns about Mr E's personal hygiene. It was reported that he was unkempt, wearing dirty clothes and generally dishevelled.

July 2004

The CPN made contact with Mr E on the 1 when he reported feeling 'okay' but she noted that his bedsit was 'dishevelled'.

Throughout July there were concerns expressed by Paradigm Housing in regard to Mr E's hygiene; they contacted the care manager three times reporting that Mr E was unkempt and smelt of faeces and was known to be in debt.

A replacement microwave was provided as the door on the original one had been broken. Mr E was reported as forgetting that he had put food on to cook and that it was getting burnt.

rd On 23 July the Care Manager recommended that the CPN re-refer Mr E to the Assertive Outreach Team. The Care Manager and the CPN agreed that if Mr E continued to disengage then a case conference th would be arranged. On the 27 a planned CPA meeting was cancelled th (by Trust) and rescheduled for 10 August 2004. 30

Panel notes and comments It was considered by the inquiry panel that the GP's assessment and diagnosis of a possible schizophrenic illness was accurate as was his prescription of risperidone. It was entirely appropriate for a referral to have been made to the mental health services. In addition, without specifically stating that Mr E posed a risk, the GP gave a warning in his referral to the mental health services in which he referred to an "aggressive outburst". In June 2003 Mr E again visited his GP. He had stopped taking his medication and it was observed that his mental state had deteriorated in the intervening months. He had not had any contact with the mental health services. The family GP re-referred Mr E, as an urgent referral, to the mental health services. He was offered an appointment with a locum Consultant Psychiatrist in July 2003. This was five months after the original referral. It is unclear as to what happened to this initial referral. None of those interviewed from the local mental health services were

With further exploration the inquiry panel found that in his letter to the GP, dated 10 July 2003, following Mr E's first appointment, the locum Consultant Psychiatrist implied that he had had a copy of the February 2003 referral letter but it is not clear when this letter was received by the Trust and what action was taken following its receipt.

On exploring the system used when referrals were sent to the mental health services, the inquiry panel were informed that the CMHT had a system whereby each referral that came in was entered into a referral book and then discussed and allocated to the appropriate professional at a weekly meeting. Despite repeated requests the inquiry panel were not able to access these documents and therefore it was not possible to ascertain whether the letter had been seen or not.

When Mr E was seen by the locum Consultant Psychiatrist on the 8 July 2003 he reported that he was leaving his accommodation because his friends there were "winding him up and making him angry. They were discussing him and saying nasty things about him". He also reported that after moving to High Wycombe he could hear people talking about him through the walls.

This report should have alerted the professionals that he could pose a risk to others, and needed an assessment of this and of the level of illness disability.

At the time no-one explored the statement that he had "gone berserk".

The locum Consultant Psychiatrist referred him for a drug screen and other tests including liver function tests.

These were subsequently found to be normal. Comment