M I C A	An arranged marriage is made in the last year of a college commerce course, which she marginally fails, bringing a woman from Bangladesh, into an extended Pakistan family living in Yorkshire, England. Her husband is a taxi driver, often away from home. Their common language is English. Mrs Kapte makes no network of her own, even after they move into their own house, which is, however, only two doors away. She generally spends the day with her in-laws, together with her children. She is submissive to them, but resentful and isolated, and complains of their interference with her children, especially the spoiling of her eldest son, to interpreters and health visitor. Her children are well cared for and perhaps indulged more than she would think right from the point of view of discipline. The marriage relationship is difficult. When her second child arrives, it is a boy to whom the in-laws give his name, overruling her own choice. Shortly after this birth, there is a first prolonged postnatal illness, finally resolved by a course of ECT, some symptoms being odd - 'there is a telephone under the carpet' but the condition being classed as a depression, when she enters a psychiatric ward for diagnosis, observation, management, and treatment. There is a serious attempt at killing herself with notes setting out aftercare for some of her children, something indicating that there may also have been a risk to one child. She receives a course of five ECT treatments. Her father dies and she returns to Bangladesh, with her husband, to some criticism from her own family. The boy - the eventual fatal victim of a fire started by his mother, is given a name for ill omen by her own family, which his mother takes to heart, and returns to, after she resumes living in England. There is never a clear and unequivocal treatment for her mental illness, the treatment being both that offered for depression in family practice, and with that, also, a medication given for schizophrenia. [ the anti-depressant is reported to be one that may carry difficulty in withdrawing from its regime ] They each may in practice interfere with the metabolism of the other, so that stopping one, may alter the blood range of the other. The uncertain diagnostic lead is part of the lack of continuity and authority in psychiatric oversight, which is broken by many changes of lead figure. The key worker is constant. A pattern develops that she remains well for a while but then discontinues her anti-depressant medication and relapses, into quite florid obtundity, recovering again with combined medication prescribed again. When ill she desperately fears for the removal of her , or transfer out of her hands into the care of her in-laws. The health vistor is the one who sees a serious situation. The serious threat to the life of one of the children contained within the presenting illness becomes obscured in clinical notes. It does not stand out as something likely to be resurgent in any subsequent recurrence. The children are always presented well and not neglected or abused. The opportunity for the local authority child services to conduct their own child risk assessment is never taken up by them and they quickly drop any offers of support or family intervention on her behalf. The final key worker is out of the picture for twenty months during a spell of two years when Mrs Kapte maintains her health, taking medication regularly, and attending out-patient appointments regularly. That time ends when an assistant psychiatrist allows her anti-schizophrenia medication to be withdrawn. Eight weeks later, a locum consultant agrees to gradual withdrawal of the anti-depressant medication without arranging monitoring observation or advising the family doctor to intervene more. Mrs Kapte stops the medication at once. Ten weeks later she has become withdrawn and peculiar.She is seen promptly and attentively by the community team during the subsequent week. The community mental health nurse is new. But the medication is not restarted, nor is the question of risk remembered nor raised by the key worker as a matter of chief concern, with the family; nor, it seems, is the situation discussed with any psychiatric clinical lead. The family are later resentful of this, feeling that with more warning and pointed information, they could have segregated and watched the children more carefully - they had the people available, and that then the tragedy would not have happened. An early out-patient appointment is made. The day before that her fears of separation from the children by admission to hospital are expressed. Mrs Kapte sets fire to the bed of her eldest son, and he dies. It seems likely all her children and herself were intended victims, although Mrs Kapte did call on the fire brigade- too late. The examining psychiatrist eventually called to examine her and recommend disposal, noted unusual beliefs which were not explicable as part of a general depressive reduction, and diagnosed schizophrenia. That would be at odds with the general picture, but agree with the We are not told of the outcome over a more prolonged observation and treatment Home Page Comment Inquiry Kapte

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