M ental I llness C oncerns A ll	His illness struck before he had accrued any educational achievement or any vocational commitment, or achieved any self sustaining life style. Everybody concerned knew things were not going well. Neale was not going to cooperate with treatment or care management. Admission never left a feeling of the professional service being in charge. The person left with the case, a community nurse, had a case load of forty, and no regularised system of supervision. Line management waited to be approached. Weekly team meetings were not led in a way which meant people in difficulty and irresolution, could turn to others for decisive intervention. In this situation it is surely right that the lay services, left in contact all the time, should be warned that things are getting into an 'out of control' position, and people should watch out for themselves. Especially should family discuss what steps they might take, with whatever resource they have - which might include total withdrawal, from any share that they might have been presumed to be taking in a total care situation which is failing. The closest clinical person, the contact nurse, knew things were getting out of hand, but not in any way different from before when people, familiar with the difficulties over a longer time, had just let things go along hoping for the best, that something in his life contact would bring him back into a direction and lead to compliance and to accepting a place in a helpful programme. There was one crucial incident which never got a full appreciation, and was never explained. Neale hit someone on the back of the head. That marked a boundary over which Neale had stepped. It did not come to any significance within the 'team'. The family had appraised the first cpn/consultant pairing. The ultimate Community nurse did not have that familiarity. The family did not have therir own separate route in with concern. Social Work, part of the team, was never involved. The carer assessment programe had not been introduced into the clinical programme. When the failing situation passed out of the hands of people who had known Neale for some years and through several admissions, into a new CPn and a new consultant who were developing their own new relationship within their recent attachments, it is likely the informal information routes of familiarity were inadequate and the formal ones found to be not up to date and not up to the job. What is not system designed to happen is a management intervention so that decisions about transfer, and acceptance or rejection of secure facilities are taken by management,and not by arrangements within the local clinical service. Here it was accepted clinically that Neale would not respond to the regular front line services, but there was no route in place to obtain the secure, the locked situation that was necessary. That usage had got lost. It is difficult to see how any new mental health Bill will deal with the likes of Neale, without a return to a more longterm institutional internment, accomanied and followed by occupational activities and hostel supervision. go to Inquiry Bradley; Neale back to Inquiries Listing         E-mail reaction is welcome mica@didgy.freeserve.co.uk