The situation in W-Lauder was similar and the consequences similar. Lauder had been withdrawn from medication which had been previously confirmed as succesfull, was ill and recognisably so, to his neighbour, and to the concern of his brother, before it could be recognised in a Social drop-in centre context. The neighbour living near him knew he was more ill.
SL was 'off duty' there, and unguarded.

JM allowed observations of odd behaviour during his stay at the Rehabilitation Unit - insufficient in themselves to be persuasive - but , taken into account with the earlier firm diagnosis of schizophrenia in the closely supervised longer stay at the previous hospital - could have raised some uncertainty that JM was maintaining a capacity to cope with personal living challenges, and decide his life aims.

Something in the attitude and appearance of JM suggested an alternative explanation - drug abuse . This was never confirmed in any blood or urine testing at the time of odd behaviour .

Untreated schizophrenia can remain minor and hidden by a patient over a comparitively short interview in structured supportive circumstances , well controlled and free from anxiety .

Symptoms may well be allowed out or 'escape' in less managed situations. JM was 'out of order'at the hostel placement .
We are not told what contact there was with his family or what they made of him. The family view of present comportment is valuable because they have a basic experience of their family member under all circumstances. They would notice abnormality.
Where professional colleagues of adequate training and experience have had a longer opportunity to observe, and to hear various reports of observation in different hospital settings, to have tried and tested with and without medication, it is best to respect that diagnosis as a working guidance.

Any observations subsequently which are puzzling must be set against the likelihood of continuing illness and of continuing exposure to 'breakdown' in that illness .

A good general rule when a diagnosis is made under those conditions, is to accept that odd behaviour arising afterwards is always to be considered as maybe indicating recurrent schizophrenia, so that closer vigilance, a review of possible consequnces - especially risk to potential victims - and to any challenge, follows. A 'little bit' of schizophrenia in those circumstances is sufficient for categorisation, where such findings initially would not in themselves be sufficient for a defining or detaining diagnosis .

Very often in the Inquiries after Homicide, observations outside the immediate professional loop , were not received or not given sufficient weight, and the behaviour during interviews, given more weight than should have been allowed when set against the reported behaviour 'in-between' .

Where this habit comes from is puzzling . It may be a reaction to the isolation, certainly felt by psychiatrists, since social work left a working relationship with the hospital admission ward, and removed the benefit of a full social history from the family source, and removed from the team, the benefit of the social worker continuing to work with the family whilst still being fully seconded to the mental health service.

This was certainly a feeling when management changes were made following the Griffiths recommendations to the NHS structure . Line management and line accountability followed, and teamwork - led by the psychiatrist , as a working arrangement , lapsed .

The Inquiry emphasises the problem of supervision, but rather glosses over the question of who is to supervise the consultant - the Responsible Medical Officer, and who is qualified to do that in practice.

There is no mention here of the involvement of a community nurse mental health service.

There is no note of any continuing contact with any family that would have allowed for their appreciation, of the current condition of JM, to be taken into account. Family will often go to lengths that others may not, to insist where they have reservations on professional care. Carer support workers - family support workers , ( Review Viner ) will help that.

The ordinary checks and balances come from those who are in the working partnership. Something has gone since the social worker - who used always to keep a contact with the family - has accepted in aftercare arrangements the barrier of confidentiality allegedly raised by the 'user'patient, who is reluctant ot permit such exchange.

But time and again it is the family who know most about the progress in competence of their family member in their illness, and to allow this source of information and experience to be ruled out of an appraisal of the presence or absence of active mental illness may well be to neglect the sufferer , and bring harm.

E-mail reaction is welcome