" Our lives begin to end when we remain silent about things that matter "

... Dr Martin Luther King

This laisser faire attitude towards schizophrenia is what we should be campaigning against. &&&&

A refusal and a reluctance to recognise that capacity in schizophrenia is to be accepted but as to be unreliable,
fluctuating as it does over time and in situation,
and limited often to particular routine functions.
They are far from being depended upon for capacity to call up help,
so can often be left isolated without reflection on what other behavior shows about the continuing nature of the illness,

' Not ill enough as we saw them ... it was their choice ... they had capacity for this as we saw them ... '

There must be a source of continuing ordinary observation, and a reliable contact with the local professional service, for intervention.

Find the person as they were, their interests, their ties and their level of matured experience
before the illness came, bring them into a normal routine, which takes account of this history, engage them there;
and so take the attention away from being led by the illness.

The whole service to schizophrenia needs it's own ombudsman ... it's own spokesman ... A leader who does not lead but will not get out of the way, is an obstructive leader.
By staying in the inner circle the circle decides what is spoken about and what is not.
Like the bankers.

Not known about till it is too late

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, 116120.

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. The public would be better protected by having a good standard of care for all patients.

The laws' delay

E-mail re action is welcome .. davidwatch@btinternet.com

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.
Mayan Coomeraswamy 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, Anthony Coombe, 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 Coombe 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 Coomeraswamy lived in Thurleigh Court, Nightingale Lane, under the supervision of South West London and St George's Mental Health Trust.
For years the landlord, Gary Burns, 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 Coomeraswamy.
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 month in 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 Coomeraswamy 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 trust's review.

Coroner rules on release of documents

... 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."

... and these

... W
.. !











from the National Framework for Continuing Health Care: July 2009
... if an appropriate clinician (see paragraphs 85-86) considers a person to have a primary health need arising
from a rapidly deteriorating condition that is entering a terminal phase and completes a Fast Track Pathway Tool,
the PCT will be required, on receipt of the completed pathway, to determine that a person is eligible for NHS continuing healthcare,
until such time as a full assessment is completed for NHS continuing healthcare, using the Decision Support Tool.
Decisions and rationales that relate to eligibility [ NHS continuing healthcare and NHS-funded nursing care ] should be transparent from the outset: for individuals, carers, family and staff alike.

41. If the person lacks the mental capacity either to refuse or to consent, a 'best interests' decision should be taken (and recorded)
as to whether or not to proceed with assessment of eligibility for NHS continuing healthcare.
42. Where a 'best interests' decision needs to be made, the PCT must consult
with any relevant third party who has a genuine interest in the person's welfare.
This will normally include family and friends.

The crucial point here is that St George's Trust NHS hospital secondary specialist Community mental health Team was the lead contact, regularly 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.

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 cuurent picture, if it might be that the GP should be doing something, or would want to be seeing the patient for themselves.

The point person - the visiting psychiatric nurse is from a team - is part of a specialist team, together with a variety of more experienced senior people, some from professions ancillary to psychiatry, to discuss things with, 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 and should consult with the lead Consultant psychaitrist for the area.
The visiting nurse can turn to their own psychiatric nurse manager if they want backing.
There is a regular weekly meeting of this particular 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.
One hopes a meeting that records who attended, what was brought up - or not, and what decision was arrived at.
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 can claim powers to intervene.
Neighbours may have informed them.

None of the above decided to intervene on this occasion.

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..


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.


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

Professional care and treatment does go wrong.

*** !!!the List of Inquiries after Homicides

linked to Comments

*** !!!What are the lessons - that are not learnt

*** !!!

Legacy cases

One piece of information from the Inquiries, where the perpetrator suffered fom schizophrenia, is that very few have been helped into a daily and weekly routine of engagement with a meaningful programme of activity, so that they will want to continue with medication

It's a common finding for most of those suffering from schizophrenia, and it is a failure of NHS provision to deliver a Treatment programme in aftercare.

Only half of the Mental Health Trusts have a Rehabilitation service which includes a consultant psychiatrist [ sometimes called 'Recovery' ] - that is, a team dealing with after-care separate from the community mental health team ( they get the first referrals ), a Home Treatment team ( often the old crisis team ) or the Assertive Outreach Teams.

These have responded and the replies are half and half, yes and no.

the No people here so that you can check the service in your area.

And Complain!!

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