E-mail re action is welcome .. mica2@tiscali.co.uk
the underlying particular case of failure to intervene is not a rare occurrence. Current attitude amongst professional caring is to leave people in the situation they have created for themselves, however disturbing and however much the professional would not choose to be in that situation themselves.
One recent visit to a single middle aged sufferer without light or heat had assaulted a neighbour by striking them with a ring of keys out of misundestandings arising from their active schizophrenia, responded to a family member enquiry about admission ... only when there is 'blood on the floor ' ... i.e they have capacity to live like that -with their illness and not come to treatment - it's their choice.
Somehow it is ignored that it is not the person behaving like this - it is the illness.

'best interests' Best interests seems to be forgotten

Community Care This is Local London, 18th September 2009 South west London's mental health trust under fire for its 'human rights' policy, Could anything else have been done ? The brother of a man with schizophrenia who died in a squalid Clapham flat criticised the care workers who feared moving him would violate his human rights. M C was found dead on January 9 this year in a filthy, unheated flat deemed barely fit for human habitation, an inquest heard yesterday. His brother, A C, accused the authorities of failing in their duty of care after a post mortem examination showed signs of hypothermia. The case has triggered a review into how local mental health services handle vulnerable patients choosing to live in such conditions. Mr C said: "My brother has been a mentally ill person for 37 years. For the last four years we know the state of his residence where he was living was squalor. I think even an animal couldn't have lived in that." He added: "If my brother died for one [reason], I hope we can learn by this." Mr C lived in Thurleigh Court, Nightingale Lane, under the supervision of South West London and St George's Mental Health Trust. For years the landlord, G B, wanted to clean the flat up - but the trust refused to forcibly move the patient to allow work to take place. The boiler was broken, the bathroom ceiling had collapsed, the walls were damp and a thick coat of dirt covered every surface. Showing photographs of the scene to the court, Dr Paul Knapman, the coroner, said: "This is barely fit for human habitation. He added: "Photograph five shows an absolutely filthy kitchen with stuff all over the place. One thing it doesn't show is rodents or insects, if there were any. I can't believe there wouldn't be." The patient, who was visited regularly by a psychiatric nurse, was found dead, partially clothed, in his bedroom after police were told he would not answer the door. A post mortem examination found ulcerations in his stomach, often found in those suffering from hypothermia. Speaking in court, Dr RA, director of social work at Tooting's Springfield Hospital, said human rights had to be considered before removing patients from their homes. She said people were only sectioned when they refused to comply with treatment, but this was never the case with Mr C. She added: " She highlighted that workers were always aware of the patient's right to choose their living circumstances, citing the Mental Capacity Act and the Human Rights Act. But Dr Knapman called for a review into the trust's interpretation of these laws. He said: "You will know that month after monthin this court we hear about elderly people often dead for weeks and weeks -sometimes months - living in absolutely appalling circumstances. He added: "The pendulum may have swung too far." The results of the review could affect adult care policy nationally, with knock-on effects for Alzheimer's patients and others living supervised in the community. Mr C came to England from Sri Lanka in 1970 to study chemical engineering, but during his last year of work experience he developed chronic schizophrenia and never worked again. The inquest, at Westminster Coroner's Court, was adjourned to 11am on Wednesday, December 9, pending the NHS Trust's review of it's conduct : and proceedings still ongoing - conclusions ? march/April 2010 City of Westminster, Royal Borough of Kensington and Chelsea, Boroughs of Merton and Wandsworth Inner West London, Westminster Coroner's Court, 65 Horseferry Road, London SW1. Tel 020 7834 6515 Coroners do not issue Inquest Reports of their proceedings. They may do so to people they think have a prime interest. The discretion is that in Coroner's Rule 20/2/h and Rule 57 You find out by direct Inquiry Tel 0207 228 6044 [ Battersea Office is serving the Inquest ] They are public, so I cannot see that anyone making a contemporaneous copy, would be barred from doing so: unless the Coroner finds it an annoyance that interferes with the progress of the inquest - inhibiting witnesses, for example. Who should attend. Sir Louis Appleby ? I don't think he will bother. The mental health section at the D o H ; fat chance Rethink, Sane,Mental health Alliance: hopefully I would expect the Royal College of Psychiatrists to attend in some way - but will they - service to schizophrenia not their heartland anymore. The Times , the Guardian for a full report, probably not. I would like it to be televised, on the radio, or put out on a DVD. ... and these ....... and these ... and these .. System failed 'Satan' crash pair, BBC News, 13th February 2009 The mental health system let down a mother and daughter and the mentally ill woman whose car killed them, a judge has said. Gemma Montanaro, who thought Satan was at the wheel, was cleared of dangerous driving by reason of insanity. Jane Malkin, 51, and Nicole Townshend, 24, died instantly on Saffron Lane, Leicester, in January 2007. Ms Montanaro appeared before Leicester Crown Court to be sectioned under the Mental Health Act. At her trial last year, the court heard Ms Montanaro was in the grip of schizophrenia at the time of the crash. The court was told psychiatrist Dr Susan Smith's recommendation that Ms Montanaro should be admitted to hospital was overridden by community health workers the day before the incident. On Friday, the judge ruled she could be cared for in the community, but would be returned to a mental health unit if she became unwell again. Judge Michael Pert said: "I have a public duty to have a concern because Ms Montanaro has been let down and the families of the deceased have been let down by, effectively, a failure in the system. Dr Smith's recommendation was not followed. Under this system, the recommendation of the clinicians will be followed. Dr Smith's care was without fault. She made a recommendation at the time, when Gemma Montanaro was desperately unwell, that was overridden and, as a result, two people died. I have seen a document that passes as an NHS report on the circumstances. It does not strike me as satisfactory." The trial heard before the collision, Ms Montanaro had been seen by witnesses driving on the wrong side of the road and through red lights at speeds of up to 70mph. Dr Jane Hoskyns, director of clinical practice for Leicestershire Partnership NHS Trust, said they had instigated a review of the care given to Montanaro. "We are making sure we understand and learn all that we can from this profoundly regrettable event," she said. "We shall support today's court decision by putting in place thorough and comprehensive arrangements for the future care of Gemma Montanaro and monitoring of her health. We also welcome the fact that NHS East Midlands is undertaking an additional investigation and, when their report becomes available, we will respond promptly to implement any further actions that might be required." Phil Hope MP Minister of State for Care Services Department of Health Richmond House 79 Whitehall London SW1A 2NS september 22nd 2009 Dear Minister, I write as a family carer for my son who has been affected by schizophrenia for the last twenty years , living at home, to draw your attention to three things to which you should give some serious attention. The first matter is the facts disclosed in the Annual Confidential Inquiry into suicide and homicide which discovered that the number of homicides committed by those affected by schizophrenia rose from 26 a year in 2002 up to 45 in 2005. The increase was from those sufferers not currently in touch with services. Those in touch continued at the same rate, but at the time were hardly being delivered care and treatment to the standard required as shown by the comments and outcome in recommendations when the events were looked into by external Inquiries. That is the second matter. Someone must draw together the comments from these external Inquiries as they display the fault lines in the delivery of service. The third matter arises from the current Inquest into the death by neglect of someone suffering from schizophrenia despite the fact that they were being visited by a representative from a secondary specialist mental health team. The Inquest is to be resumed. The questions raised by the circumstances are such that I believe it imperative that some one from the Department should attend the resumed inquest. If the standards of intervention into the care and treatment of people affected by schizophrenia, as given here in the newspaper report of the early proceedings, are those practised throughout the mental health services, the situation of those affected by this very serious illness, is one of continuing jeopardy. Something must be attempted to give guidance for the long-term monitoring of those with this illness, whose insight into their illness is reduced and fluctuating, and who cannot always reveal what is going on in their minds. These three matters raised, point the need for a greater degree of supervision and intervention where this illness, is left outside a service, or when the service is a faltering one. I append the newspaper Report. Is it significant the Inquest had hardly any national press publicity? Yours sincerely David H Yates FRC Psych www.schizophreniawatch.co.uk a reply 23 October 2009 Dear Dr Yates, Thank you for your recent letter to Phil Hope about mental health services. I have been asked to reply on Mr Hope's behalf. I was sorry to read of your son's mental health problems and can appreciate why you feel strongly about this issue. As you are aware, The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness provides definitive national data for England and Wales on in-patient suicides and those in contact with mental health services in the year prior to death. The Inquiry is crucial to gaining a better understanding of the circumstances surrounding suicides and homicides by people with mentai illness and to reducing risk in this group recognised of being at high risk of suicide. The Department is committed to taking appropriate action in response to the findings of the Inquiry. As you know, any rise in numbers relates to homicides by non-patients - people who were not engaging with services, not people who were accessing services or being treated. You may be interested to know that around a third of people with schizophrenia are not patients or service users. Some service users can present a challenge to services in terms of the complexity of their illness and their engagement with services. The Department needs to ensure that we have the best systems possible in place to identify warning signs and train staff appropriately so that risks are minimised. However, the Department knows that not all incidents are foreseeable or preventable. To help manage people effectively and safely in the community the Government introduced community treatment orders in the Mental Health Act. Although it is not possible to say that they will prevent all such tragedies, it is possible to say that they could be usefully employed particularly in the treatment of individuals with a history of non-compliance in the community, potentially reducing the risks they pose to themselves and/or others. To further support mental health services to provide effective and safe care the Department of Health has published Best practice in managing risk: principles and guidance for best practice in the assessment and management of risk to self and others in mental health services. It underpins risk assessment with principles of good practice for al! mental health settings and provides a list of tools that support effective risk management. The Department has also published its review of the care programme approach (CPA); this includes how risk assessment and management is incorporated into CPA systems. CPA is the system of assessment, planning and a review of care for people receiving secondary mental health services. Over the last 18 months, the Government has been talking to a wide range of people and organisations about their ideas for better mental well-being and better mental health care. The Government knows that good mental health is important to everyone. A lot has been done to improve mental health care but we need a new approach that will build on that as well as targeting the root causes of mental illness and improving people's mental well-being. The Government's new strategy, New Horizons: towards a shared vision for mental health, sets out to do just that. You may be interested to know that, on 23 July, the Government launched a public consultation to give everyone the chance to have their say on its new vision for mental health and wellbeing. The consultation closed on 15 October 2009 and Departmental officials are currently looking at what people said in response to the consultation. The Government plans to publish the final New Horizons approach before the end of this year. You have also raised concerns about the death of an individual patient who had schizophrenia. As you are aware, an inquest into this is currently underway and it would be inappropriate for the Department to comment whilst that is ongoing. I hope this reply is helpful. Yours sincerely, Sally Greenbrook Customer Service Centre Department of Health Sally Greenbrook Customer Service Centre Department of Health TO00000447070	B r e a k s . . i n . . t h e ... W e e k ' . . a r e . . . U n m e t ... N e e d s .. ! 10 20 30 40 50 60 70 80 90	Who decided on his 'capacity' to decide to live like this? Who considered the degree of activity in the illness schizophrenia - that requires a psychiatric opinion qualified [ sec 12 ] to give consideration and recommend under the Mental Health Act, taking into account the observations of those who have been familiar with the behaviour; agreement with an Approved Mental Healh worker, and consultation with the nearest relative. ? At what level of qualification and what at level of personal observation, was ' there is capacity ' decided. The psychiatist has seen C at home with the brother; the brother had attended team meetings. The team members seems to have been decision makers here. What treatment was being accepted is not made known. The circumstances of personal neglect would suggest oral medication was not being taken. An excess of tablets would be found. or prescriptions not renewed or claimed. It seems likely that a depot medication regime was in being . The question then is - was there other community and carer observation which would point to the illness [ other than the neglect ] continuing to be active , so that combining that active illness, together with the neglect , the illness could be declared to be active and of a degree to warrant Mental Health Act application. The crucial point here is that St George's Trust NHS hospital secondary specialist Community mental health Team was the lead contact, regularly visiting. He was receiving NHS lead continuing healthcare - aftercare visiting. When a top NHS team specialising in serious mental illness, is doing the monitoring of the care and treatment of someone who has been affected by a serious and enduring illness, other people, who would otherwise have an immediate concern, influenced by the care being with people who are better qualified than them to know when to intervene with this illness, they back off - ' they are the specialists - they know what they are doing'. The GP will not stay in the picture, unless the team keep the GP service regularly updated. Did this happen. Were there letters to the Gp appraing th GOP of current situation and Team decision with explanation ? Was the GP asked to concur with leaving the patient to neglect themselves, as though they retained capacity for an effective choice even with a residual schizophrenia, even when the choice is detrimental - it is a patient of the GP that the team is looking after. The issues about choice and capacity in schizophrenia, here are crucial, and difficult to be confident about, often with an illness whose degree is variable and with incomplete insight. On what sort of observation and interview did the team conclude the neglect was a personal decision made by someone with capacity This was not a 'leave me alone' . The visits were accepted. A decision about capacity to choose to live in deteriorating neglect would lead to consideration of a second opinion, especially if a close observer over time, of the continuing behaviour , like the carer brother, showed concern. How much did what mayan coomeraswamy say to his brother, away from the team, was then taken into account. Without this team visiting, the GP would be visiting to see the situation for themselves, probably at the behest of the family, noticing that the situation with this serious mental illness , was going wrong. That the GP is out of the picture will be known to the team - to be taken account of, and if necessary, re-visiting the need to bring the GP into the current picture, if it might be that the GP should be doing something, or would want to be seeing the patient for themselves. The point contact person here - the visiting psychiatric nurses are from a Community Team - are the pivotal participants - crucial to the inquest proceedings - part of a specialist team, together with a variety of more experienced senior people, some from professions ancillary to psychiatry, there to discuss things of consequence, if there seems to be a problem developing. The team will have a senior clinical lead, usually a psychiatrist, who if not a consultant will be able to and should consult with the lead Consultant psychiatrist for the area. The visiting nurse can turn to their own psychiatric nurse manager if they want backing. There is generally - without it would be poor practice - a regular weekly meeting of area Community mental health Team - held so that matters of concern will have a forum to bring to bear senior experience, one that has the authority within the Mental Health Act [ MHA ] to make decisions. What the visiting community team nurses raised at the meetings during the last years of deterioration, and what was discussed, there is crucial information for the Coroner to consider. One hopes meetings that have records that can be produced, of who attended, what was brought up - or not, and what decisions were arrived at. Was there ever a consideration of admitting, for closer and more continuous observation about the level of activity of the schizophrenia ? In the team will be Social workers with mental health experience If a Mental Health Act decision was proposed, an Approved Mental Health Worker, usually one independent from the secondary Specialist hospital Team, would at some stage have to agree that grounds for a MHA section were there, for an admission to go forward. Sometimes preceded by, sometimes accompanied by, two medical recommendations; one by the family doctor with some recent contact, and one by a section 12 MHA approved specialist, usually the consultant psychiatrist in the specialist team. For urgent necessity , one medical recommendation suffices. In self neglect on this scale, the Local Authority Welfare Social Services people, even the Housing Department, can claim powers to intervene. Neighbours may have informed them. None of the above decided to intervene on this occasion. Patients who need aftercare through the obligation to provide that follows Mental Health Act treatment Section detention, or by the situation of the patient establishing a continuing NHS health care need . That's an obligation to provide. It may naturally follow assessment or informal admission. Other St George's Inquiries Inquiry SP and TW Inquiry Barrett Inquiry death Chattun To the Editor: British Journal of Psychiatry Septembe 2 2009 Re 'Still the Heartland' ' We all like to have anchor points of certainty in our lives, and even in psychiatry, with its whirlpools and eddies of doubt, we are searching for reminders that some fundamentals remain unchanged. The trouble is that relatively few are left ... such ... were lead words from the Editor in July, at the same time as the publication of the annual National Confidential Inquiry. The increase in homicide figures by people suffering from schizophrenia between 2002 and 2005, reported on in the National Confidential Inquiry into Suicide and Homicide is alarming and unsettling, or it should be to the profession. The comments by the lead author that this is not down to 'patients', but people outside 'the system', is not reassuring. The care and treatment revealed in the Inquiries that follow , where patients are participants in tragedy, show 'patients' equally not embracing the system. The general silence that has followed the publication in July, unlike the flamboyant media attention to single tragedies, goes to confirm the view once expressed in the Journal that schizophrenia is no longer at the heartland of psychiatry When the serious mental illness schizophrenia saps the reliability of the authority the sufferer has over the continuity in their own conduct, those around them are entitled to expect some way of bringing observations of such illness into the purview of those who have such an authority to intervene; those who may use the mental health Act, to bring to bear on schizophrenia, the secondary specialist mental health services at their disposal, and to expect them to be able - and willing - to exercise those provisions. The division between LASocial Services and NHS responsibility for after-care and continuing care provision has meant that neither builds up the systems to replace in the community, what the mental hospital provided: a regularity of shelter, and a framework of daily and weekly occupation, limited though it was when the hospitals accumulated many times more long-term ill than it was funded to look after, and resettle. It is a wrong that only half the Mental Health Trusts in England provide a Rehabilitation [and Recovery] service which has a lead psychiatrist in the team. ... We all like to have anchor points of certainty in our lives.. Sir, Such a framework is absent for these sufferers. It can only be assembled by a team that stays in existence over time long enough, powerful enough to claim the funding, active enough to acquire the knowledge in the local area that will provide , as a routine in their lives, this regularity of activities in the week ahead, outside themselves, that bring a focus, and a pinning structure, for those collected inner associations, which form the default priming internally, for the intentions ahead. D H Yates FRC Psych family carer. www.schizophreniawatch.co.uk A reply Dear M(r)s Greenbrook, In paragraph four I must make two comments. That 1/3 of people affected by schizophrenia are not patients or users partly reflects the comment above: they are not in touch with the local service Many of those have been discharged from the secondary service, often to their family homes, on the basis of 'nothing further that we can do' - or have just dropped out finding after-care arrangements too complicated or too unattractive for them to keep up. They are not people successfully brought into the secondary service, nor discharged because well and not now vulnerable. You will know that those perpetrators of homicide who had been in the service, are subject to Inquiries. Very few of these examinations are without reservations about the standard of care delivery. It is regrettable that the Department is not interested sufficiently to ensure these are made available on the websites of the Strategic Health Authorities. The DoH Chief Executive requested that all legacy case Inquiries since 2002 be found and published by July 2008. Many were late in achieving this. But one in particular is recalcitrant. The North West SHA has still not made a link to them available on its website despite many requests to do so. Delegation of responsibility does not mean washing your hands of any subsequent failures. It is surprising that neither the Do H nor the National Patient Protection Agency, has obliged that SHA to follow the request of the Chief Executive. It doesn't fit well with taking the findings of the National Confidential Inquiry seriously, nor with ensuring ... the best possible systems are in place, ... so that risks are minimised ... Taking seriously means acting, and engaging thoroughly. All that does not particularly encourage confidence when it comes to the Department reviewing and following Community Treatment Orders. To be useful over the long run as a consequence of CTO's there will have to put in place a sustaining routine in their lives of a sheltered kind that captures their commitment, or there will be 'drop outs' of the kind pointed to in the National Inquiry. Less than half of the Mental Health Trusts have the kind of active outreach linked to a Rehabilitation service with the kind after-care that provides and sustains the occupational routines required to keep those with long-term schizophrenia in touch with continuing care. They are unable to meet the requirements of full time work. There has to be a rehabilitation service in all Trusts if those with continuing vulnerability in after-care are to be kept in touch with the service. The end of the National Standards Framework for the mentally ill and their carers should not be taken to mean that the priorities set out in the NSF have been met. It may well be that most with serious and enduring mental illnesses have seen enough improvement but the service to schizophrenia and their caring families, is not better, and in many respects is worse. New Horizons must retain the priority to the service offered to those affected by schizophrenia. It is a singular illness, with many idio-synchrocies, and should be singled out Primary Care Trusts have never replaced in the community service the sheltered activities that were there for the long-term in the mental hospitals. Pentreath Industries in Cornwall, set up particularly to do that in 1996, for those to be in the community, was never given development funding by the Cornwall NHS commissioners , and was, disgracefully, allowed to jettison it's original purpose. If you can read my letter again, you will see that I do not want a comment of the proceedings of the Inquest. I do however, expect a Department concerned with the needs of those who cannot get those due to their illness, provided for themselves, to read and take in the account, provided to you by me, in the local newspaper of what was and will be considered, in the continuing proceedings in on December 6th . Those considerations are fundamental to the proper standards in delivery of care. You do need to know what is actually going on in the secondary mental health service. What I request is that the Department delegates someone from it's section that deals with mental illness, to be at the Inquest. It should also be a proper concern of the National Director who advises yourselves about the outcomes of those in receipt of the care and treatment provided by the secondary mental health services. Yours sincerely, Dr D H Yates copy to Sir Louis Appleby The Royal College looks at risk - risk or proper aftercare ; quotes Eileen Munro, PhD and Judith Rumgay; PhD London School of Economics. Role of risk assessment in reducing homicides by people with mental illness. British Journal of Psychiatry, 176, 116-120. Predictability of homicide Eleven inquiries (27.5%) concluded that the violence could have been predicted and 29 (72.5%) considered that there had been insufficient evidence to alert professionals Twenty-four (60%) of the patients had a history of violence or high-risk factors for violence but in only eight did the inquiries consider that there was evidence for judging them to be high risk at the time of the homicide. Sixteen patients who had long-term indicators of violence did not show any imminent signs to indicate that their state of mind was changing significantly. ..... ..... Mental health services have a dual commitment to maximise the welfare of patients and to protect the public from harm. The policy of community care has, for most patients, led to improved quality of life although the level of funding has meant that they have not received an optimum level of care and treatment. Treatment in the community rather than in isolated institutions has, however, made people with mental disorders more visible to the general public. Their behaviour can, at times, appear strange and frightening. They can actually be violent, usually to themselves but very occasionally to others. Their victims are usually relatives or professionals known to them, with only 13% being strangers (Taylor & Gunn, 1999) . As the public inquiries show, there are serious obstacles to increasing public safety by improving risk assessment and targeting services on those deemed potentially violent. Mental health professionals have limited ability to predict rare incidents of violence. However, they have considerable skill in diagnosing and treating mental illness. [ Ed: - And assessing the degree of present illness, part of which is assessing risk; part of which is assessing capacity ] The article concludes succinctly " The public would be better protected by having a good standard of care for all patients. "