M ental I llness C oncerns A ll	There was not sufficent failsafe contingency in this management of a 'first go' psychotic illness. The companion carer did not know what was a satisfactory reaction to her observations and concerns, when the professional involvement was not given - at their point interviews - enough of an account of symptoms by the patient. The carer would think the doctors knew best, and could tell sufficiently what was wrong at their interviews to achieve the proper response. The doctors though they had not enough grounds for urgency or for compulsory intervention. Another naive victim is killed and nobody is to blame. Carers who meet together know only too well that the professional staff will not react to being told of illness behaviour by observers, even close family observers . THEY have to see it for themselves , or they will ..they would say .. they can .. do nothing. To the carer on hand, it is at a different level of involvement, which the aftercare did not match. Schizophrenia can be open and cooperative, especially treated. More usually - without medication - it is secretive and tells 'lies'. That is not being able to remember or recall what was going on at the time of odd and frightening behaviour, and so being unable to recount it to any professional, but only to say what seems to be required to be expected, and to get out of their hands. D.Ph. was known to deny illness - as revealed in the initial interview with the family doctor - at a time when his wife had recorded a change into very odd behaviour That should have been a warning to be taken into account when he 'broke down' again outside hospital. He would not be a 'patient' and tell all. That should have been conveyed to the community doctors and to the carers and a fail-safe conduit into immediate community visiting by the mental health service should have been made available at the time of discharge. It is insufficient to leave it to lay carers to decide what level of illness is serious. It is not right to leave carers of severe mental illness, even when that is settled by medication, without a route in to the channels which have greater care facilities. Both the wife and the Consultant agree the wife had been told - 'get in touch if concerned' . What was not 'a given' was what was meant by 'concern'; nor the way to get in touch .... a telephone number, an out of hours response service number, a social worker connection; nor how to lay out the level of concern before these contact people so as to get an immediate reaction. The Inquiry Report is so light as to seem exculpatory. There is no list of witnesses. There is no explanation as to why this Inquiry Report is published six years after the tragedy. [ It was overtaken by the one which reviewed the death of Brenda Horrod - but no clear connection disclosed other than two members being the same. ] It does not describe the general mental health delivery arrangements provided for the catchment area. It is content - two of this Panel were at the previous local External Inquiry - that looked into the circumstances of the death of Brenda Horrod - to follow the findings of a previous examination of those in that Inquiry ....commenting of what there was at the same time as D.Ph. was in Hospital .. " this was a service in crisis reaching breaking point " It does comment on the wisdom of making a Consultant psychiatrist the key contact ... " in view of the multiple responsibilities of consultants and their inevitable frequent unavailability" . There are unanswered questions, important for any lessons. Was he taking the tablets which were at a dose that had previously dealt well with this schizophrenia.? Nothing is said about a check upon this point - even after the tragedy. Were any found? Would a blood test have decided this uncertainty and could it have been enforced after arrest. When ill he originally denied illness. Another concern that is not fully addressed is the 'double barrelled' medication system - medication taken together which are directed at two different conditions, schizophrenia and psychotic depression. Keep it simple to take is good general advice. One medication can alter the blood levels in the other. He had a job to go to and was pressing to be outside hospital. But this is a first exprssion of a severe mental illness. The after care support and level of contact does not deliver authoritative intervention in this severe mental illness where insight is lost and the outcome of which had not been finally resolved. Inquiry Armstrong; Phillips ( Coleman ) back to Inquiry links	E-mail reaction is welcome mica@didgy.freeserve.co.uk