M I C A	The service given by this Forensic Team gets a good going over. Perhaps because this is a prestige Institute and the Inquiry were taken aback by what they unearthed. A 'top gun' is wanted by all manner of advisory bodies and committees. His commitment reminds me of comments made to me during a busy week - today, you come home tired - you have not seen any patients - you have been in committees. A Medical Director from the Institute published his saddening reaction to the proceedings in a professional journal. With some effect. As an example, the Panel is deliberately and stubbornly sceptical about the observation and conclusion on LwL, from last visit of the Community mental health nurse to LwL, new to visiting LwL but with previous in-patient observation of him to set against her visit. She is adamant that there was nothing untoward to note during her half-hour visit which would have enabled her to foresee that something might erupt out of illness in a weeks time- into the final denouement. The Inquiry Panel remains unconvinced - disbelieving that no signs of illness could be seen by an experienced observer - without offering much as to why they should be so doubtful. Vol 1pages 178 - 181 Their minds were made up. They had the bit between their teeth. They knew that no medication was found on testing from sample taken at the time of his final arrest. Their puzzlement is not necessary. Those who judge the influence of illness must reconcile themselves to the hazardous nature of an assessment of the level of activity of this illness ......at one point in time, from one point of view Having the illness, and the person having it revealing its presence to an observer, are different matters. The Panel is correct in noting that off guard - outside the prepared and structured setting of an interview odd behaviour is more noticeable and stands out. This point of comment has to do with how to monitor oral medication compliance by judging the reappearance of illness. (*) The Consultant had traded off relinquishing the hold given by depot medication against retaining thecooperation of his patient in any future circumstance. His comment is .. ' that the therapist position would be helped if the Tribunals had said directly ... your freedom depends upon your accepting depot medication' - rather than ..'you will take medication as directed by so-and -so ' - which allows for a bargaining position. Or in other words: compulsion is welcomed but only when done by others. That is behind the move to Mandatory Community Orders, based not upon capacity - which LWL showed he had on the point examination a week before the event - but on the continuing assumption that anything odd is, in the personal case of someone with this diagnosis, grounds for reacting at a different level of intercession - to an illness which is active - a volcano upon which an eye and an ear is always open, and a prepared intervention already accepted, ( the 'blom-cooper' dilemma ; from history, an illness is there waiting to surface. When do you intervene with compulsion ... Blom Cooper; Robinson ..... even if the outcome may doubt that to have been unnecessary? ) The experience is that if negotiation is allowed it is felt as a basis for doubting the strength of belief in what the person in charge is doing, and draws someone with schizophrenia into pursuing the ambivalence. If it was really necessary it would be imposed, insisted on without allowing argument. 'It can't be that necessary, I,ll challenge it.' This Inquiry is incessantly detailed as it strives to make retrospective consideration and sense of a personal practising work habit. A senior practitioner has got into a habit of using ways which have served him well till now. He is senior enough to believe that patient decisions are his reponsibility alone, arising out of his personal exchange of trust with his patients. He has wide commitments which have grown into his way of coping and caring.		He defends his stance at every point. Which is why the Inquiry Report is so lengthy and detailed. What he is given as a team by his mangement is archaic. There is no team working to keep updating the community activity of someone under restraint in the community. There are three people - a probation officer, a community mental health nurse, the consultant - who speak on the telephone - but never meet as a review body of people working together. The visiting nurse does not seem to have a line manager to whom he can express any reservations he might want to raise, and should raise. The natural people who are obliged to keep ahead of events in their mutual locality are the family and these are not given weight - or in the case of the mother - seen as an ambivalent emotional figure in the report - given any credence. Matters which are explicable, understandable, and excusable in ordinary folk - irritability, anxiety merging into anger, singularity , cannot be overlooked when the illness schizophrenia has previously been substantively diagnosed. The long lead must go wherever they go. The Panel, highly critical of the personal style of decisions of the consultant, covers all the adjunctive material it can. It rightly finds the business of day to day maintenance and renovation of a dwelling, of subsistence problems , of occupational activity pursuits , to be a likely source of frustrations, of anxiety and anger, whenever there is residual illness, and wants a higher standard of provenance to go into this. The consultant colleague in the medium secure Unit has a social worker in his team. But they are paid by the Trust and do not have the independence of Local Authority line management to turn to when they think things are going badly, or are disapproving or have reservations about the foundations for medical confidence coming from formal interviews with the patient alone. The Trust management has not accepted the discipline of the Care Programme Approach, but has put nothing in its place. Just a self-satisfied contentment with things as they are supposed to be without any examination of what care in the Community has gained in experience elsewhere. Resting on old laurels will not do when there are great changes going on all round. Old peer group exchange meetings have gone with the new management style. The Community Social Services in the locality were never approached. An alternative neighbourhood locality community Forensic Team which had a clear working team practice could have been invoked and referral to that was discussed but rejected. If the mother had known of that she could have asked for a second view. Indeed it is striking that this is never an option offered to any of those in the cocoon of people examined by any of The Inquiries after Homicide, however much they expressed their dissatisfaction. It is not clear that a route to this kind of helpful oversight will be available in the new Mental Health act as presently envisioned. This is worrying. It makes it all the more important that the family, usually the most persistent of those who keep contact and feel an obligation, are backed up with some clout. It can come from the Local Authority Social Services reverting to an old function - to obtain a social history and to maintain contact and exchange with the family - or significant people in the cocoon, and represent their experience, their observations and their views in review at regular updating mental health team meetings. And to continue to champion the family interest as a balance to the health attitude - which is apt to be trapped in the engagement with their patient to the extent that they cannot get into the life of the caring cocoon - people that knows the behaviour of the patient in the real world. Who is to intervene in the best interests of someone - someone who is going along with care and treatment which are not appropriate to them , and when no one is on hand to notice and challenge it. The people who will do that are usually family - but how do they get into the system. If the subject does not complain, neither can they. The Mental Health Act Commission may do so for a detained person, on request from an interested party, but rarely do so. They must if a detained patient demands it. This is a doubtful asset for someone whose illness and capacity may deny them any awareness that what is being done is going wrong? What if medication is producing side-effects noticeable and which will be disengaging when living in the community? What if going without medication is wrong - relapse has happened before- but a patient with seeming capacity request it. If nobody with professional access to purview is there to see a wrong consequence, and to be ready to intercede - what then? Who will be able to put that to the attention of - who? Will lay 'carers' be sufficiently allowed through the gate to insist upon a professional reconsideration ?.. E-mail reaction is welcome

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