M ental I llness C oncerns A ll	A very difficult singular situation to be in. DJ is deaf within a large overcrowded family, before he could acquire language facility or family stability. He recovers some social ability, personal appreciation and respect, at a boarding school, but during holiday time he is probably sexually abused by a play leader. He has a preoccupation with an American wrestling clique, and much misunderstanding about his chances of joining that activity. He is big and strong enough. Face to face he is generally personally pleasant. He hates being deaf and is often despairing and frustrated. There are times when his mood fluctuates - later it affects his sign writing and some of the clang associations within that point to an illness - the manic-depression in the Affective Illnesses. Following a recognition of this by a psychiatrist competent enough in sign language, he receives mental illness service as an in-patient in an ordinary mental health unit, and the trouble - whatever it was - subsides during a course of medication with the new neuro-leptic risperidone. He is seen by a neighbourhood specialist in-patient Unit for the Deaf who are mentally ill. He is transferred to that unit, a national specialist service rather than a local service with its own local aftercare, continues his medication and shows no symptoms of illness during his stay. This first contact, in early adolescence, but progressing peacefully, hints at all the difficult problems to come when different agencies become involved, which will ultimately bring about disaster. There are already three neighbouring Units taking part. A specialist deaf consultative Unit in an ordinary mental hospital, an ordinary mental hospital with no in-patient deaf communication services, and a national Unit for the deaf which by coincidence is close-by, but which does not offer an emergency admission service, or a locality in-charge service. They will lead aftercare to reinstatment, but can offer no direct intervention when things go wrong. Complicating everything is the LA Social service ability to provide interpreter service to whoever calls for it, so that at different times with different agencies, a different sign interpreter is there. When he is released from the National Deaf mental illness Unit - national - a tertiary unit serving the whole of Southern England - but geographically very local to him, they arrange with the local Social services - local Hostel accomodation, with an eventual residential place to be sought at a nearby Training College. These arrangements rely on a place coming up and on funding being in place from Local Authority Education Authority - yet another agency. The final arrival point is delayed and procrastinated. DJ is less and less biddable, looking to young person freedoms. He flits between home with his mother, and residence at the hostel, and under these circumstances his self medication is erratic. Two months before the disaster , somehow he comes under the influence of a drop-out alternative life style, low income individual who has the occupation of a house which is open to people om Social Security Benefit, drifters, a drug supplier, and two dogs. His step-father goes along with the move into what reads like an old fashioned deteriorating squat for the inadequate. In doing so DJ has moved into a new catchment area whose base is the nearby community team attached to the original hospital team which covers the previous address of his mother and which referred DJ to the nearby National deaf Unit. This National Deaf Unit, where he was finally an in-patient, does not inform that referring hospital service of his release, nor his family doctor, ( who prescribes the medication) It is never clear why this is - the National Unit here seems to be taking on itself the charge of local follow-up - because of its deaf communication abilities - without introducing any contingency arrangements with locality Services. This will be because whilst an in-patient in their Unit he remained under medication and was never showing any signs of illness. He was perhaps seen as an easy customer to follow around - 'in touch' as they saw him.? The National Deaf Unit knows he is now living in the catchment area of a mental health service which does not know him, and the National Unit knows it may be that service which would be called in, yet it does not inform them or invite them to intervene until two days before the final outcome. Instead it finally informs the community team of theoriginal Unit, who visit and recognise difficulties but at the time of the visit see no indications of a need to intervene quickly. They point out he is living in the catchment area of the neighbouring service - whose centre is in the same road nearby - but neither does that intervention, nor those that follow, make any contact with that neighbouring Unit. The advice at that time is formed under very difficult interview restrictions and that is given as a qualification to the fullness of any advice. It is that advice relied upon by later sevices who do not make any personal contact, but assume the examination was more recent - two weeks - than it was - actually eight weeks earlier. The final realisation of urgency is expressed by the National Deaf Unit Community nurse who cannot give the impetus of personal knowledge to her request for active intervention and admission. It is made to the locality catchment area community crisis team who have never seen DJ, who ask the local Social Serrvices mental health Approved Social Workers to make an assessment for admission !! The request is passed around between community teams and left with a Local Social Service Approved social work Office, who has no prior personal identification with DJ, to make a mental health assessment for admission. They hesitate - they have another priority, and then their arrival is too late. Summary:- the setting; a very deaf adolescent prematurely breaking free from family. Predisposion to failure 1. an illness leading to inner impulses, which is treated with medication and maintained free from illness in a structured setting but in the hands of an adloescent in poor support situations and self medication, will be less controlled. 2.The social aftercare is separated from the health aftercare. 3. The specialist deaf unit has no facility to intervene directly in locality breakdown. They do not hand back healthcare to the referring mental health team. 4. Social breakdown indicates health breakdown. 5.When his own social arrangements breakdown, he is in an adjacent catchment health area which does not know of him. 6. The family member who is always in touch cannot contact the active agents, because the intermediating care holder is the Deaf unit, which has no crisis responding ability themselves. The helpful agency turns out to be the obstructive one. Summary conclusion : - (!) a so-called (*)crisis team has in fact no ability to respond directly to a crisis that requires resolution by admission, but has to pass this decision on elsewhere. a community mental health team must have in it representatives of the three core services, psychiatry, social worker, mental health nurse, sufficiently senior to initiate executive action, who meet regularly enough as a review catchment team to know what each can do. Review	E-mail reaction is welcome mica@didgy.freeserve.co.uk