M ental I llness C oncerns A ll	The Report introduction states that ...' by vigorous inquiry the Panel would establish the facts - and , in particular the information that was available to carers at the relevant times. ... no hindsight would apply ...but an open mind ... was there a lapse from good practice ? ... if so, would it have made any difference ...even if , no .... then ... is there room for improvement ? ...' How would the panel judge good practice - by what standards - the care programme approach certainly - national advice - but who and what would inform the Panel of the 'good practice' - the material point here being when to intervene and take charge - we must assume it is the judgement of the Panel psychiatrist, and the view of those experts that the Panel chooses to consider so; and the old court judgement - what holds as good practice in the general run at this level of execution as applied to this particular situation and circumstance. This is an illness known to recur. Forearmed with this knowledge the remaining business is how can it be anticipated, forestalled, prevented or cut short. The armamentarium available, in this case is limited. One factor is the lack of a live-in carer, who can report when a change of mood has become a settled pattern, so that intervention is drawn in early. The cocoon that might have been instructed or involved, were the married daughter, the other adult children, and the supporting religion - the measure of support within the stance of the latter contact, to be taken into account. The best buy for preventing recurrence of affective disorder is daily lithium medication, or sodium valproate - less well established but maybe more acceptable as lithium requires blood monitoring. Another way is to prescribe regular anti-depressant medication that has been tried and found to work in previous phases of the illness. This was never clearly established here. But some believe that regular medication of that kind will mean that the abnormal mood, if it comes is more likely to come as 'high'states - here, what it was crucial to avoid. What was used was a depot neuroleptic drug, which may have the effect of nudging someone into depression. On that account it was eventually withheld. An anti-depressant preparation which would not affect the heart rhythms was chosen, during the final year, but insufficient note is given of its availability or use in the weeks before the last event. There is no clear decision available about preventing recurrence - certainly the crux here - so it follows that early intervention is likely to be the chosen form of management. That requires a prepared position, shared with all who are likely to see relapsecoming. What information willcome available and what it can be gathered in, is then important. MA had moved catchment areas. Neither the new Consultant nor the visiting nurse had personal working knowledge with MA when she was ill - were familiar with what she was and what she said and did when illness was coming on her. The Report panel seems not to have looked very closely at this. It has not asked for the working relationship between the monitoring by the visiting nurse and the level of her discussion with the family doctor or the Consultant, about the grounds they might lay down for more active steps,what were the grounds allowed for immediate review, or more regular visiting and contact with the family. But what sort of other arrangements could be made other than timely hospital admission - easy to say timely but impossible to be certain about the need - or a more thorough check on anti-depressant medication - it is hard to see. The final move into irrationality and complete loss of insight was so abrupt. Fore-warned here could not mean fore-seen. Here, yet again, her children, who knew her normal mood limits very well, felt she was becoming ill, when the professional staff at their point examinations did not see enough to say to themselves - the illness is here and we will watch out more intimately. What they or the family could have done can all be challenged as hindsight. The family, in a real community with an extended family setting , might have had a companion to move in and sit it out. In the good old bad old days , there might have been room for a precautionary observation period in hospital. Not nowadays with a schedule of management efficiency in accounting bed occupancy - and over 100% usage, and generally a poor ambience, and irregular staffing. There is neither room nor time for ruminative thinking over of the uncertain options, in a safe place. Professional health workers do not now think of that as a possibility. The old hospital function of holding in protection has gone. Inquiry Taylor; Alawode	E-mail reaction is welcome mica@didgy.freeserve.co.uk