M ental I llness C oncerns A ll	Not in this case. This illness has the pattern of affective illness - that is episodes of illness with mood alteration of some duration, with clear cut longer intervals of freedom from illness. The depression is often minor, intermittent, and assessed as contemporary worrying about matters of concern. Then there are more flagrant outbursts when the excitement is accompanied by extravagant statements - messages from God - and misbeliefs - she will inherit the hospital premises - which carry a 'high'connotation and - taken with the overall longtitudinal pattern suggests the diagnosis would come into the affective group. That is periods of steady and then mixed mood chang, interspersed with longer periods - of normality for this particular person. More in favour of a diagnosis of schizophrenia -are specimens of 'made' passivity experiences, but this is never a sustained condition,and does not linger with the usual attributes of continuing schizophrenia. Assessment is complicated by the fact that she is on maintenace depot medication- more usually given to continue to neutralise schizophrenia. The diagnosis is never secure and confident. This may undermine the significance of milder harbinger symptoms and signs e.g. sleeplessness. MA and her second husband lived in the beliefs of Jehova Witnesses, and she and her separated second husband were guided by elders in those beliefs. The Panel notes that it may be difficult in this context to know what weight to place on religiose statements as stated by MA and when interpreted for depressive or grandiose significance by a professional at interview. It is not clear whether the Panel heard from the elders, or that the professionals engaged them, or the family. The illness is first noticed during steroid treatment for benign raised intracranial pressure. Next after pregnancy which is known to produce a mixed picture of psychiatric illness when there is a sudden onset. Through the two years before the final tragedy, there is minor symptomatology - tiredness, anxiety, and a fear that illness is returning, about which she is reassured. MA is much concerned with the possibility of sexual abuse of her small daughter, because of complaints after her weekend visits with her father. Nothing is found on examination. It is this daughter who is killed by MA. The third and final episode is preceded by a some days of depression, and then - after the tragedy - she says it suddenly turned into high pressure of thought and grandiose affect. It is unlikely any intervention could have anticipated or prevented such a sudden switch to overpowering illness. Nevertheless the Panel thinks a visiting professional may not have made much of depressive content over the weeks leading up to the tragedy, attributing them to a physical illness. The family doctor provision did not get involved in the latter stages, although Prozac - a general anti-depressant - may have been prescribed - whether taken or not is not clear. Some gastro-intestinal trouble can follow as a side-effect. MA had gastro-enteritis some two weeks before the tragedy which may have interupted any compliance. Both the psychiatrist and the key worker community nurse were overloaded with patients. There was supervision , but it is never clear what sort of supervision was available to the visiting nurse, what habitual use was made of it, or what sort is an acceptable level of oversight, or to whom she was expected to report . There is no account of team meetings or team review processes. MA was seen by her psychiatric Consultant at out-patients a month before the event, and by the visiting nurse two weeks prior to the event at the home of her brother, and the day before - without finding anything worrying. This Inquiry notes - like many others - "It is a major concern that professionals may not get to know patients enough whilst there is so little time for face to face contact. Residual psychotic symptoms can be present without interfering with day to day activities and may not be freely admitted". It is noted that the children and MA herself are worried she is becoming mentally ill ... KW (adult daughter)..." knew well the signs of her mother becoming ill " . Reviewed	E-mail reaction is welcome mica@didgy.freeserve.co.uk