The title of this Inquiry Report reminds that it is not the event that is examined, but the care and treatment given by health and social service system to someone who was ill over a long time, and the systems that delivered those interventions. " The needs of carers have been firmly placed at the bottom of priorities of policy makers, health and local authorities, even though the carers role is often central to the people with enduring mental illness. "
The Inquiry is adversely critical of the Local Authority Housing Department, for leaving this ill man without a domicile to use as his own. His apartment was not protected when he was detained in hospital.
But which was to be called to account : the housing system for not having available options; or the health service for being unable to insist on regular medication to keep him well enough to use an abode properly; or the social services for lacking mental health experience, for intervening late, and for backing off finally from their responsibility to be there for the predicament of the mother.
Her frustration was with the indecision of all the systems.
There was rarely a time when all the systems worked well and realised a common plan.The only person to keep in constant contact in the later three years was his mother, and she had to cope with shifting sands, without her feeling anyone else was taking charge of this ill person, without any sense of there being any authority, any continuity in caring , without anyone making themselves accountable for professional care, within the separate services or between the separate services .
Local Authority Social Services had rather gone its own way. Their mental Health experience had got lost in generic work, in a neighbourhood obligation, so that even the specialist mental health Approved Social Workers - those able to make application for admissions - were unable to keep up with their statutory requirement to do so many of these in a year. At supervisor level , the Social Worker involved with checking the work of the social worker key worker for MM, although a qualified ASW had no actual experience at that level of mental health work. In the last year of his care, MM - and his mother who was only the continuity - was assigned only duty roster social worker backup; changed from the casework required in this care situation .
Even initially when one ASW kept a close link with MM and his mother , and worked closely with the CPN service, there was never any meaningful Mental Health Act Sec.117. aftercare review of his position. The psychiatrist was never there. So far as multi-disciplinary plans in hospital were concerned these were tacked on, an ad hoc arrangement with the social workers getting a telephone ring from the ward to say the psychiatrist was there and to send a social worker.
The Social worker at the early stage of MM being ill "always there for his mother "... had recorded her confident appraisal
".... evidence of deterioration ( of MM ) is usually secondhand through his mother , whose judgement can be relied upon".
However, she needed protecting from coping with him beyond the point where he has become a danger, in particular towards her ."
After that, the last three years are described in the Inquiry report "We find the service given to MM and his mother was poor, and fell short of what is expected ..."
His mother stands as a Brechtian heroine, the face worker, let down by 'them'.
Although she knew when he was seventeen that he was becoming mentally ill, he could never be brought to early intervention. She had to cope in the family for three years before any 'help'.
Even the original event which exposed his illness to public response - the Court appearance following grievous bodily harm to his girl friend - went wrong. She received legal advice that it was better MM went to jail rather than announce his illness and have him sent to 'life' in a secure mental hospital.
The Inquiry is resigned to reporting in sad reflection a repetition of what is noted in the Inquiries before their own.
"There was little value placed upon, or consideration given to, [ the mother ] Mrs C's contribution as a carer. Those professionals who should have worked more closely with MM when he was well seemed to regard her contribution as a convenient substitute for the after-care plan which they should have prepared.
" They told me that if he wasn't harming himself or someone else , he could not be sectioned " .
And last - as all family carers can confirm ..... " Throughout MM's illness, Mrs C. effectively put her life on hold ."
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