M ental I llness C oncerns A ll	The Chair has imposed his own structure on this Report - quite different from the structure in most Inquiry reports. It takes a while to adjust and find the aspects wanted. What Inquiries do is examine the care given at a particular point in time.This Inquiry report is useful and comprehensive in laying out the systems and framework background both national and local, to the application of the way management expects delivery of mental health resources. But it lacks a clear description of what management had purchased and provided - what were the limits within which care at that time had to be delivered. The health/social services division - barrier almost - does not receive the weight of scrutiny that this reader thinks it should. It correctly acknowledges the lack of engagement with the views and experience and observations of the family and concerned observers, but is unable to say where and at whose door should be laid the responsibility for this lack of interest. This is not to apportion blame but to point to weakness in the system that needs correcting. Similarly it notes that there is no constituent psychiatrist in the mental health community teams. Who then is the clinical lead? Local Authority social workers are regular members. There are six community multi-disciplinary catchment area teams. The report comments parsimoniously - ' two consultant psychiatrists were associate members of the service'. The multi-disciplinary team has no acknowledged medical lead within it. The Report reads as though a community mental health team with any catchment area individual concerns may have had to go to the in-patient ward rounds of four different consultant psychiatrists. At the time of the in-patient admission both the long term staff psychiatrist, and the ward consultant for the catchment area, are on leave. The lead clinical relationship between the community teams and consultants is not more closely answered. Other Inquiry reports have found the absence of a clear lead position a worrying matter of concern. Especially where social workers have a key worker contact position and have to decide about clinical illness levels of concern. The standard of concern does not always seem to be the same as that adopted by health. The intervention crux for an ASW is the detention threshold - the loss of liberty - often- 'not sectionable in my view ' ; since Blom-Cooper/Robinson - for health it is a change in the level of illness or a change in the level of support - a loss of medication acceptance - which warrants - requires - a change of supervision and intervention - in the community; and a review for admission to care for the illness which will come. The community caring 'cocoon' is helpless in the face of professional detachment from their concerns. There is never a proper appraisal of A. in his social hinterland. In the chapter 'Local Framework' a management guidance is reproduced - the seventh management principle to be adopted is :- " Carers needs and rights must be addressed by providing information and support as quickly as possible, in a way that is most appropriate for the individual carer or family, and by involving them in care plans" . This is a usual deference to the presence of lay carers - but it does not address the obligation to be put on on professional carers to be in contact, sufficiently to hear, to record, and to consider the views, the experiences and the observations of the behaviour 'in-between' professional contact which lay carers have, without which the opportunity to come to a clear diagnosis falters, and therefore what will fall also, will be the chance to formulate a full community care plan. Again and again the information, which is available in the community where most caring occurs - from the family particularly, is not sought or obtained by professional decision makers, thereby denying themselves the basis upon which to give a proper service to the patient who needs their careful decisions. Not to make good arrangements to obtain this information, can lead to negligent care, and not to get it can be negligent. In one of its paragraphs in 'Findings' the Report explains one reason for not talking to family and friends - the neighbouring 'cocoon' - ...' because staff were perhaps over concerned with maintaining strict confidentiality of patient information - essential to risk management '.What does this mean? Staff wanted to encourage A. , by promoting a sense of privacy and trust, to tell them of impulses to attack people - because he would think they would not tell anybody else !! But they would then be obliged to tell the potential victim - as A. would know !! He had already attacked his step-mother. It used to be that when a social worker was involved with an admission it was customary and natural for a social work report , to accompany, or follow shortly, the admission - formal or informal - and the views and realtionship with family would be part of that , as would be the nature of that relationship as revealed at the time of the ASW assessment. That central commitment - they will need this information to be able to consider the best interest of X - now has gone, everybody grudgingly leaving the responsibilty of being there for the patient - to somebody else. The Inquiry Report writes it is not there to lay blame, that subsequent acts are the consequence of a multiplicity of small events . Either the information that the Report says was crucial yet was not found or passed on, is a substantial one - to be substantiated - or it is not something which stands to the light of day. That is this Inquiry Report just leaving things 'in the air' as a general smudge for the whole service , when it should be something that has been a particular narrowly placed criticism, and one that is now corrected. The diagnostic predicament is not made clear. Yet this professional decision rules in its consequence. The homicide is stated to be planned and from 'matters not related directly to mental disorder' but there are no details to look at to see whether the illness was still a major factor. Inquiry Eldergill; Allum	E-mail reaction is welcome mica@didgy.freeserve.co.uk