M ental I llness C oncerns A ll	Schizophrenia is a serious mental illness, always likely to persist in some form, and ever open to exacerbation under uncertainty and stress, and if medication is insufficent or lapses. Here nobody got to grips with his first illness presentation in 1972 when he was 27and living in london. He was not retrieved when he absconded, and he then drifted in illness for four unsupervised years. A responsible and more authoritative medical lead in the old hospitals would have done better : longer detention and supervised aftercare leave Subsequently he took aggressive and dangerous assaults, mis-believing his daughter was in danger from the people whom he attacked. This leads him before Court; thence to a Special Hospital. He is then decanted, away from his first domicile area, where he might have been known and some oversight, community observation, and future stability perhaps might have been easier to achieve and maintain, to start again in a different town and begins twenty years of compulsory supervision whilst in the Community. The mental health service offered is a forensic Clinic, based twelve miles outside from the neighbourhood where WW will now live. The psychiatric element may not have the local nous and contacts that a local general psychiatric team would have built up. Without his family and childhood mores to react to him and for him, there seems to have been no hope here. Streetwise drug skills, and exploitable women in an alienated world, seems to have been what he thought the achievable and succesful way for him Some doubt must remain about the diagnosis. It is unusual for schizophrenia to be enough coherent, and with the drive necessary, to allow the degree of social manipulation described in this Report. An alternative diagnosis of cocaine induced symptomatic schizophrenia or even manic-depressive illness would better explain how WW was able to survive. By skilful scheming, by dealing, by evasion, by manipulation and by leaning upon the good will of women. The Inquiry Report reminds that at low medication dosage, a remaining schizophrenia can seem to represent personality faults. They become accepted as within normal limits undwer the circumstances. With a previous firm diagnosis of schizophrenia the correct response is to return the dosage in the medication regime to the previous level. WW was succesful in pulling the wool over the eyes of many people. Depot injections were given at the clinic base. Testing for drug abusewas complaisant He was seen to have a prepared specimen ready to forestall random testing. Clinical lead and social workers were not working together in a team fashion, under the discipline of the Care Programme Approach giving each other information exchange, but rather proceeding separately and in parallel, each thinking the other was in an ' in charge' position - which was not the case. A black social worker is previously more assertive and intrusive with WW. He believes WW may be exploitative with his colour and background, to get away with non disclosure. WW might make white people uncomfortable at exercising authority over him.He is eventually threatened by him. This does not come out as serious. The story recalls the previous Inquiry [ No 45 Scotland; Luke Warm Luke ] also a forensic care.The professional contacts are building the Trusting Relationship, developing the therapeutic alliance so that the bonding will release future disclosures. The attitude often goes along with a reluctance to go to neighbourhood informants for in-between observations. That would break confidentiality and destroy the trust in the face interviews. The patient bargains for a lower medication dosage. The final social worker coordinator is overstretched in his work, complains about this, but his supervisor does not do anything but exhort a shedding to a reduced work load and then, it seems, leaves the matter there. There is no systematised operation of line manager led peer group discussion with face workers, held regularly enough so that members feel easy at bringing forward any difficult and uncertain positions. Line managers are content to wait to be approached, rather than take a proactive stance and engage themselves in work-face talk. [ ... The Robinson Inquiry raised the importance of supervision years ago with little in practical consequence. There is such little certainty with severe mental illness that mentoring availablity should always be built into working practices. Especially where uncertainty about risk contiues. The old case conferences were some sort of attempt at bringing out stances and attitudes amongst senior colleagues who were there to appraise junior staff presentations, and were open in return to their own appraisal. Tutors were often a way in to raising 'complaints'. Regular mixed staff admission ward 'rounds' were similarly the opportunity to raise doubts and uncertainties. Very few of the Inquiries after Homicide are able to point to a catchment area working practice which brings together mixed team catchment reviews - the opportunity for matters of concern or neglect to come before a forum. Regular multi-disciplinary team weekly meetings attended by sufficiently senior people - if known to happen in a catchment area - can be a means of getting observations out of the neighbourhood coming before the whole team, and getting attention. It is the regularity which gives easy access. .... ] He has not done a home visit for eighteen months before the tragedy. The coordinator settles into an office approach rather than an assertive neighbourhood intrusion. Things seem to get along, mostly. The psychiatrist lead notices no reason fro alarm. They are both unaware of the real situation and have lost real working connection with each other, each relying on the other. At the immediate internal Inquiry - mandatory, and here led by a Health Authority non-executive Director - the Social service line manager prevents the appearance of the Coordinator Social Worker at the hearing - it is unsuitable, he is being disciplined by the LASocial Services - appearing by herself instead. What transpires at the disciplinary hearing gets no airing. The internal Inquiry is a round table gathering. It's Report does not go to the delivering Trust. We are not told any detail of the final homicide WW pleaded not guilty. Inquiry Johns; Williams Comment Home Page         E-mail reaction is welcome mica@didgy.freeserve.co.uk