Adapted from the report of the inquiry supplied by Pat Fitzgerald, of
Southern Derbyshire Health. Mounted as HTML by Chris Evans
C.Evans@sghms.ac.uk,
24.xi.96 within the
Section of Psychotherapy pages
Names and some details have been changed. Where
names have been changed the substitutions are consistent, where
places have been changed this is not necessarily the case.
XX (formerly ZZ) was born in xxx and brought up in xxxx. His father had left his mother before he was born. When he was two, his mother remarried and XX was adopted and took the name of his stepfather - XX. A half-sister was born in 1976 and a half-brother in 1983. He was told of his adoption at about the age of 8 and this appears to have given rise to no change in the family relationships. His period of growing up appears to have been unremarkable and presented no difficulties or unusual signs until he was about 13 when he tended to withdraw from family activities. This was thought to be a relatively normal impact of adolescence. It was not until he was 20 that serious tensions appear, especially between Xx and his mother, and even then there was apparently no violence, although his father did think that he might be making threats to his mother.
His school record was not particularly good but he did gain some CSEs. He left school at 16 and secured a Youth Training Scheme placement in a warehouse. He did not complete the year, feeling that he had not the ability to become a van driver. There followed a series of short periods in labouring and factory jobs. With hindsight, it now appears that his mental illness was certainly showing some effects by the time he was 20. He appears to have had a number of friends, with whom he, for example, attended football matches. He was telling these friends of his own age of some of his problems, which included an indication that he was being troubled by voices. This information he did not disclose to his family. His friends have reported that he had an adverse attitude to his mother, including some aggressive feelings.
His period as a member of the T.A. appears to have been reasonably successful and did not give rise to adverse comments on his sociability. However he had a large number of short periods in employment and does not appear to have integrated closely in any of these. He increasingly appears to have spent considerable time in solitary pursuits - walking, running and cycling in the surrounding countryside. In 1994, on one of his excursions, he was violently set upon by a group of young males and this led to him taking a greater interest in collecting weapons 'of defence', and carrying one of them on his excursions 'for protection'.
The tendency towards isolation appears to have been reflected at home where he began to spend a large part of his time alone in his own room. The family appear to have felt, not unreasonably, that XX should be encouraged to set himself up in independent accommodation. However he appears to have lacked confidence and made no serious effort to do so. There must have been some tension as a result.
(ii) Medical History
XX was registered with a local practice based at XXX. It is a practice of four doctors (one part time) and although they do not have separate lists there tends to be an informal grouping of patients with particular doctors. Dr Yyyy appears in recent years to have worked with the X family and they would generally see her.
His early medical history has little of significance. He had some experience of cannabis and a single experiment with 'magic mushrooms'. It is obvious, in retrospect, that for four or five years he was developing a schizophrenic illness that was giving rise to difficult relationships at home and worsening an unstable relationship with his mother. He appears to have become very health conscious and keen to keep fit, but much of this may well have been an attempt by him to lessen the symptoms of his illness.
He appears to have had a good attitude to his doctors, consulting his G.P. from time to time, for relatively minor medical problems without his deeper problems becoming obvious. His current G.P., Dr Yyyy, first met him in May 1994. He complained of tachycardia and was referred to a cardiologist who identified no physical cause for his symptoms. It was assumed that the problem was psychosomatic. Dr. Yyyy herself had been able to see that he had some personal problems and decided to refer him for counselling. Her reference to counselling sums up the impression he was giving-
"... having a lot of problems, having arguments with his mum, not sleeping well, and having nightmares.."He was allocated to Mr AAA, a qualified counsellor on professional placement, supervised by Mr BBB, one of the counsellors regularly used by the practice.
He was assiduous at attending counselling sessions, with Mr AAA, which XX appears to have valued. These continued up to, and briefly after, his admission to Derby City General Hospital. The sessions were treated as therapy and no reports were submitted by the counsellor to his G.P. - this was apparently the usual practice.
We have not been able to discover the extent to which he confided in his counsellor (but had there been clear signs of mental disturbance we would have expected this to have been reported to his GP) and prior to his admission to hospital it was only skilled questioning by his GP, Dr. Yyyy, which uncovered these hidden thoughts.
Dr Yyyy saw him again in October 1994, for a separate medical matter, and next saw him in May 1995. She appears to have had no occasion to examine XX again over those months and the question whether he was during that time showing overt symptoms of a mental illness to anyone with whom he came into contact cannot be known. He came next to the surgery on the 25th May 1995, on his own initiative, complaining of sleeplessness and nightmares. On skilled and direct questioning, he disclosed auditory hallucinations and paranoid features. Dr Yyyy felt this needed specialist attention and so she decided to make arrangements for an assessment by a consultant psychiatrist. She made contact with Dr CCC, a consultant at Ward Q of the Psychiatric Department of the Derby City General Hospital, who was the Responsible Psychiatrist for Dr Yyyy's area, requesting an urgent appointment for XX. This was fixed for 14th June. The psychiatrists from the hospital routinely held clinics at the G.P.'s clinic. The patient was advised to bring with him a member of his family or a friend.
A letter of referral, setting out the outline facts and the G.P's impressions, which included the marking "urgent", was sent to Dr CCC and appeared to be received on 5th June 1995. On it is noted the arrangement of the subsequent appointment for 14th June 1995 at the outpatient Clinic. It clearly indicates Dr. Yyyy's preliminary opinion of developing schizophrenia.
XX duly presented himself alone, despite the advice to bring someone with him, at the Outpatient Clinic where he was examined by Dr CCC. He had apparently not told his family of the appointment. It was clear that he was suffering from paranoid schizophrenia. There were suspicions that he might be dangerous and he needed to be in hospital for a full diagnosis and treatment. He said he was happy to be admitted as an informal patient and promised to present himself the following day. Contact with his family was made by a G.P. at Dr Yyyy's practice who passed on Dr CCC's opinion that XX needed hospital treatment and would be admitted on the next day. She was clear that immediate treatment was necessary and that an Order for Assessment under S.2 of the Mental Health Act would be appropriate. But as XX was fully co-operative she did not think that at that stage an Order was required. She kept this possibility in the forefront of her considerations for some days but as there were no signs of XX being unwilling to co-operate, an Order was never felt to be necessary.
Dr CCC wrote to Dr Yyyy, Xx's GP, detailing her initial assessment prior to admission. It was a reasonably full report setting out her impressions, briefly summarising his personal history and background, medical history and detailing his mental state on examination. The conclusions indicate that he had "a severe mental illness". This required treatment in hospital, and the patient had agreed to come in informally. Should he change his mind his illness was such that he would be assessed for compulsory detention under the Mental Health Act.
It is clear that Dr Yyyy in May 1994 was able, without difficulty, to assess that XX had underlying personal problems that were affecting his general well-being. Her choice of counselling, at that stage, seems to be very appropriate, and within limits was very successful as it gave XX some much needed confidence and support. On his visit to the surgery a year later, Dr Yyyy was quick to identify first rank symptoms indicating schizophrenia and she acted quickly to ensure that he was fully assessed by a Consultant Psychiatrist.
(ii) The use of Counselling
There were good reasons for referring XX to counselling in 1994. It appears to have been appreciated by XX and given him some reassurance and support. His persistence with it, even after his breakdown and period in hospital, gives the clearest evidence of this.
However, it is difficult to be precise as to the exact objectives of the counselling. Our lack of formal access to the counsellor's notes of what transpired at XX's meetings with the counsellor make a full assessment of the purpose of the sessions and the benefits XX derived impossible to make. It is clear that, in spite of a year's counselling sessions, XX's psychotic symptoms were not detected.
It is also debatable whether the sessions were continued for too
long a period without a review of progress, but since XX was keen
to remain in contact with his counsellor, its not being terminated
is understandable. Even though we have no indication of the impression
XX was giving to the counsellor, the lack of communication with
the GP does not appear to be wise. It is possible that the concept
of confidentiality could inhibit a referral to appropriate specialist
help. This is a most important matter for consideration that arises
from our enquiries and we expand our views in a special section
below, dealing there in particular with the more general questions
as to the organisation of a counselling service and the appropriate
integration of the work done by the counsellor into the general
pattern of medical and social work help available to a patient.
On the day after his out-patient appointment, on 15th June, as arranged, XX came to hospital, arriving by himself. Dr CCC had told Dr. DDD, her Senior House Officer, of his impending admission. Dr DDD received him and spent some forty-five minutes or so talking to XX and recording her impressions of his condition in the Medical File that had been opened for him. She had no doubt that he was showing clear symptoms of schizophrenia, but found him very forthcoming and interesting to talk to.
XX was admitted as an inpatient to allow consideration of his symptoms that were indicating schizophrenia and for any subsequent treatment thought to be necessary. It was his first admission to a psychiatric hospital. On the day of admission a care plan was formulated by the nursing staff - this requires the nomination within 72 hours of a "named nurse". This was not done at first, so there was no "named nurse" in existence whilst the orientation, planning, implementation and evaluation phases were being initially considered.
Admission information was routinely sent to the Community Mental Health Team who would have responsibility for XX on his discharge - in this case the xxxx Community Mental Health Team (yyyy). It seems likely that they were told informally.
On XX's admission Dr DDD, on Ward Q, spoke to Dr CCC and checked her opinion on appropriate medication. XX, who had indicated he was not keen on medication, was told of what was proposed and seemed to accept what had been decided.
The patient was further discussed at a Multi-disciplinary Meeting (MDM), comprising medical, nursing, and occupational therapy staff, which noted the appropriate medication, and decided that his mental state was to be initially assessed so that, should he unilaterally decide to leave, it would be clear whether he could be detained under the Mental Health Act, by use of S.5(2), followed by an Order under S.2. Dr CCC's initial impression was that this might well be required and was to be considered as a possibility.
Every day, at each change of shift, the staff would consider how each patient was and report overnight observations. Other than difficulty in sleeping, for which he was given Temazapam, XX presented no problems. He was described as a model patient.
On 21st June, Dr CCC decided that the progress made by XX was such as to allow a period of leave over the next weekend. This decision, which is the responsibility of the Consultant, was based on a discussion of all the information available. It appeared that XX had not reported hearing voices for several days, appeared settled and was prepared to continue with his medication. One of the principal sources of information for decisions was the multi-disciplinary meeting (MDM) which was held in Ward Q weekly, on Thursdays. No formal notes were taken of these meetings as such but references were made to matters of importance in a patient's notes, as appropriate. These meetings supplemented the Clinical Ward Rounds which also took place weekly, at which the patients were seen and reviewed by the Consultant. The "named nurse" did not attend as a matter of routine.
Xx indicated that his father would pick him up for the leave but, in fact, he went home by himself. Appropriate medication was prepared for him and he was to return on Sunday lunchtime. The weekly MDM decided to continue the care plan as envisaged.
It is appropriate to note at this stage that XX's father recalls visiting, with his wife, in the evenings, four times during XX's first week in hospital. On at least one occasion XX's brother David came too. Mr X is also aware that XX was visited by some friends of his own age on Saturday, 17th June. On each visit the family first reported to the nursing station on Ward Q and enquired for XX. XX would then be told they were in the waiting room and would arrive to see them. None of these visits are recorded and there was no contact at any time with professional staff.
On the 25th June XX, after his leave, returned to hospital. He had little to say at first about his period at home but he later indicated that he had not got on well with his mother. He also said that he wished to discuss this with Dr CCC.
It was reported to us that on 27th June, because of the progress XX was making, he was allowed out of the hospital 'for the afternoon'. We subsequently learnt from XX that he had been spending considerable time out of hospital without permission. On some occasions he says he went to town and on others home. His absence was not authorised nor recorded and the staff of Ward Q appear to have been unaware of them. It appears that a provisional decision had been made to discharge XX in a few days' time. Due to his reluctance to accept oral medication it was decided to medicate him by injection. A test dose of Depot medication was accordingly given on 28th June. This decision was recorded in the nursing notes of 28th June.
On the 28th June his father, who was expecting his son to be discharged, came to the hospital to take XX home. He had on this occasion sought an interview with Dr CCC at which he expressed considerable concern about Xx. Although it appeared that XX was back to his 'normal self,' Mr X pointed out that his son had weapons hidden away and in particular a steel baseball- like bat with a serrated edge had disappeared. He also reported that on XX's last leave he had found a small number of XX's tablets discarded in the bin. He reported that he was causing difficulties and said XX 'is splitting up the family'. The family had been concerned about his safety for two years and could not understand why the counsellor had not "picked something up". This information appears to have been noted but it was made clear that XX would be discharged in the next few days and the plans for his after-care were explained. The need for the family to keep in touch with the hospital and the G.P. was stressed. Dr CCC suggested XX rejoined her with Mr X. They discussed the tablets but, because Dr CCC sensed an increasing discomfort during the discussion, and so as not to heighten the tension still further, she did not proceed with the three-way discussions beyond that point. The question of weapons does not appear to have been raised.
However, the concern shown by Mr X in his interview with Dr CCC contributed to her decision to substitute a period of leave for the intended discharge, so that XX's behaviour could be monitored further before actual discharge. The intention was that XX would return on 6th July, have a further Depot injection, and if all had gone well, then be discharged. The "named nurse" does not appear to have been involved in these decisions.
The MDM on 29th June, after XX's departure, confirmed that he should have a week's leave and then be discharged, unless further problems had arisen.
Xx returned by himself at the end of the leave on the 6th July. He was seen by Dr DDD and not Dr CCC, who was available for consultation if necessary. He reported that there had been some difficulties during the period of leave - he had felt somewhat slowed down and had had an argument with his mother. More positively he indicated that he had been given his job back. He was given a further Depot injection and discharged.
On the 13th July, a discharge letter, written by Dr DDD, was sent to Dr Yyyy. It gave a résumé of the admission, family history, personal history, mental state on admission, examination and investigation and the treatment and progress in hospital. It gave a full account of relevant matters but it must be noted that there was no mention of the concern XX's father had reported over his collection of weapons, nor of the apparent tensions in the family, nor of non-compliance with oral medication. It is impossible to say when the letter arrived at the G.P.'s surgery but it was estimated that it should have come to the attention of Dr. Yyyy within a week after it was written, but it does not appear to have done so.
The indication of progress in hospital also included some information about his employment problems. Because of Xx's ambivalence on this it was necessarily rather uncertain.
The follow-up arrangements were set out - he would be seen by Dr CCC in the Long Eaton clinic. It was important that if he did not comply with treatment he should contact the hospital or his GP. Father was thought by Dr CCC to have agreed to "keep an eye on medication" but he has no recollection of undertaking that responsibility. The medication given on discharge was recorded. It consisted of Depixol injections fortnightly, Sulpiride twice a day and Procyclidine as necessary.
Ward Q is a general psychiatric ward, in a relatively recently built unit, in the grounds of Derby City General Hospital, which is a large general hospital with extensive facilities. These include a range of psycho-therapeutic activities and recreational and social provision. The Ward serves a population of approximately 108,000, most of whom are from the nearby towns of xxxx and yyyy. There is accommodation for 25 patients. Although located on the Derby City General Hospital site, it is owned by and forms part of Southern Derbyshire Mental Health NHS Trust.
The ward operates a recognised nursing model based on Hillegard Peplaus. Patients are allocated a "named nurse". There is a strong emphasis upon the development of nursing skills and of team work. Appropriate courses for the upgrading of skills are held. The Ward is approved for both Project 2000 Mental Health Branch students and for Conversion of Enrolled Nurse Training.
The mental health resources linked to the ward are
XX has since indicated that he was very bored by his time in hospital. No doubt, to an extent this was due to his personality and illness. Although there is apparently a full programme of activities XX appears to have done little and he says that he frequently left the ward, and the hospital. He had been to town, and even been home, several times. Surprisingly, most of this absence appears to have been unauthorised and undetected. He had not wanted to take part in most activities. He had been told there were facilities in the hospital, such as a general workshop, which it was thought might interest him, but he showed no inclination to attend. However, he was keen to use the gymnasium but was told that there would not be an acceptable level of supervision.
(iii.) Nursing Policy
A system of "named nurses" is operated, each patient being allocated a specified nurse within 72 hours of admission. The patient's "named nurse" will attend the MDMs, according to availability, but not as a matter of routine. The Ward Rounds involve the Consultant, the Junior Doctor and a nurse, usually the nurse in charge of the Ward. It so happened, because of leave - of both patient and nurse - that XX's "named nurse", EEE, did not attend any of the MDMs. There was, however, a 'green sheet' system of general communication, by which matters of importance could be reported in the notes and so would come to the attention of all review meetings. It is a matter of chance that during XX's stay, because both he and his "named nurse" had periods of leave, they were both in the hospital at the same time for, it would seem, merely five days. Although there is a system of "associate nurses" to ensure continuity of care, in this instance the practice did not comply with the policy.
(iv.) Care Programme Approach
Although the Ward operates the Care Programme Approach, the allocation of XX to Level 1, which is itself a surprising outcome of the assessment, meant that there was no special planning of care for XX subsequent to his discharge. Whilst he was in hospital, apart from the need for routine medication, involving injections given by the Community nurses, no other factors were identified as requiring continuing attention.
However, on 20th June, whilst in hospital, XX indicated that he had been sacked and that this was worrying him. A staff nurse (not the named nurse) undertook to contact his employer to explain the situation - and presumably try to keep the job open. There is some doubt as to how far this happened. He does appear perhaps to have regained his job but very shortly left, whether on his own or his employer's initiative is not clear but in practice he cannot be said to have 'gone back to his previous employment'.
It might be thought difficult, except with hindsight, to be critical of the allocation of XX to Level 1 of the Care Programme Approach but there does appear to have been information available that would have indicated that a higher level was prudent. Certainly events indicated that there was a real need for a higher level of supervision and support.
One of the underlying factors affecting the evaluation must be that XX, newly diagnosed as suffering from schizophrenia, had contact during his stay in hospital with the qualified medical staff, which was clearly inadequate to have a proper appreciation of his progress and the difficulties he was likely to encounter at home.
(II) Medical assessment
There is no doubt that the medical assessments made initially by Dr DDD and subsequently confirmed by Dr CCC, who had already examined the patient before admission, were completely correct. Similarly the choice and doses of medication whilst in hospital and on discharge are in conformity with good medical practice.
Markedly less attention, however, was given to the more general aspect of the patient's general needs and to his social background and difficulties. This has several elements;
More generally, the lack of communication with XX's family is unfortunate, if possibly explicable. XX appeared to be an adult and self-contained young man; his relatives had not apparently pressed on his admission for an early meeting with the doctors; his illness looked to be relatively easy to control and release from hospital might secure a return to his job. One of the factors that may well have influenced the approach was the current importance given to confidentiality, for it has to be acknowledged that as XX was an adult there may well have been hesitation in involving others without explicit permission.
Yet it is the failure to recognise fully the social aspects of XX's problems, rather than the medical treatment of his classical psychiatric illness, that proved to be one of the most important and unfortunate aspects of his care.
(III) Social Work Involvement
The reason for the lack of social work involvement whilst he was an in-patient is one of the most perplexing features. On admission, all the information available came either from the admission letter from his GP, who did not know the family especially well or from the facts volunteered by XX himself. Although the matter was no doubt given serious attention at the time the Care Plan was considered it is difficult to see that this could be fully effective without a wider range of information from XX's relatives, and perhaps his friends and employer, being available.
It is important to note that neither XX nor his family had had previous involvement with the Social Services. There had been no request for help with the problems that were arising.
No reason has been established, other than a concentration on medically treating XX's symptoms, to explain the absence of a referral to Social Services. Furthermore, no inhibitors to such a referral have been identified, such as impaired working relationships, resource problems, or lack of confidence in the ability of Social Services to respond.
At strategic level there exists a sound Joint Planning framework, and at local operational level there are agreed joint operational procedures, supported by joint training. Particularly relevant are the processes to recruit, train and accredit Approved Social Workers, which have been undertaken on a joint basis with local health services, and which have resulted in adequate numbers of these specialists in Mental Health work being available in local Area Social Work teams, and in Community Mental Health teams.
Support for this work was also available from a range of services including occupational therapy, day care, either at home or in day centres, and more generally through links with other key departments such as housing and employment.
Social work support to Psychiatric Hospitals is provided from Area Social Work Teams and from Social Workers based in Community Mental Health Teams. As such the management of the service is not unified yet but moves towards this have begun.
Given the psycho-social nature of the impact of schizophrenia, and other severe psychiatric illnesses on the patient, relatives and carers, it is important to ensure that a multi-disciplinary and multi-agency approach is always adopted.
2. There should be adequate social work resources available to support the implementation of Recommendation 1.
3. That the role and responsibilities of the "named nurse" should be reviewed, including the extent of the responsibility to co-ordinate the services given to the patient.
4. That "associate nurses" be appointed for each patient so as to ensure continuity of care over the three shifts and during other absences of the "named nurse".
5. That the "named nurse", or an "associate nurse", should be present at all occasions when decisions are being taken as to the future of the patient. This is especially so with regard to the consideration of a patient at the weekly Multi-Disciplinary Meeting. Records of key decisions should be co-ordinated and kept available for consultation by the team of "named" and "associate nurses". Any plan of action should be communicated to those concerned. The responsibilities of the "named nurse", as set out in the Philosophy of Care for Ward Q, are excellent and should be adhered to.
6. The care plan should specify a programme of activities within the Ward Programme relevant to the patient's care and to assist rehabilitation.
7. That the "named nurse" should have a duty to make and maintain contact with the appropriate relatives, friends or carers of the patient so as to form a link with events and opinions of importance to the making of decisions involving the patient.
8. Following leave - weekend or long leave - a clear record of behaviour and incidents at home should be ascertained. Where appropriate, relatives, friends or carers should be interviewed.
9. The co-ordination of the various sources of social work assistance to patients and discharged patients requires careful consideration.
10. All staff should be made aware that crucial information, for example, the knowledge of some non-compliance with oral medication and of the interest in and possession of weapons, should be communicated to the multi-disciplinary team and to the clinical ward round and a system devised to ensure this takes place. An ongoing assessment of risk should be an integral part of the process.
11. Prior to discharge, a package of care should be arranged to meet the individual's health and social needs.
12. Discharge should include provision for feedback, properly documented to maintain accuracy of information.
13. Where an intended discharge is delayed for further consideration, a full review meeting should be held prior to discharge being granted.
It is good practice that consideration of a patient's needs on discharge should start as soon as possible after admission. This procedure is enshrined in the relevant local policies but does not appear to have been adhered to. The failure to assess and pass on the difficulties that would face XX was detrimental to the determination of the level of care required from the community team. In particular, no mention was made of social and family difficulties. The same weakness can be detected in the timing and content of the Report sent to his G.P.
1. Outline Summary of Events
On 6th July XX was discharged and his supervision was handed over to the Community Mental Health Team in xxxxx. A team member from that area was usually in attendance at the Ward Q MDMs so might well have been aware of the plans for XX's discharge. Instructions on the treatment XX was to have were sent to the xxxxx Office.
On the 13th July, a discharge letter, written by Dr DDD was sent to Dr Yyyy. It gives a fairly full, accurate résumé of the admission, family history, personal history, mental state on admission, examination and investigation and the treatment and progress in hospital. There was no mention of resistance to medication, of any potential family difficulties, nor of the possession of weapons.
The indication of progress in hospital also included some information about his employment problems. Because of XX's ambivalence on this it was necessarily rather uncertain.
XX visited his G.P., on the 17th July to obtain certificates relating to his employment and again on 27th July. Dr Yyyy appears not, on these occasions, to have seen the discharge letter or summary. The letter would usually come by post, but in some instances the patient brings along a summary. There is no record of the date on which Dr DDD's report was received by the practice.
FFF, a Community Support Nurse (CSN) was allocated XX, who did not, from the information available, appear to present complex difficulties, although his hostile attitude to medication was known. The process of allocation appears not to take into account the features of each individual case. There is no practice of liaison with the G.P. The nurse first rang XX's home on 10th July. XX seemed happy at his getting into contact. Mr FFF found out that he would be able to visit XX at home but XX made it clear he was very reluctant to take an injection. XX also indicated that he was aware of the nature of the medication and its side effects, and did not wish to continue with the Depot medication, but he agreed that he would see Dr CCC.
On the 19th July, FFF visited XX, taking a Depot injection with him. He saw XX by himself. In the conversation they had, XX was relaxed and open, showing some insight but appearing overall very flat. He discussed hearing voices but said that they had lessened since he was taking the Sulpiride. He checked that XX had a supply of tablets which he said he would continue to take and offered the injection which was adamantly rejected. He indicated that his non-compliance, and his previous discarding of tablets was because they did not mix with alcohol. XX also reported that he had "left" his job. He indicated that the nature of the work had changed from that before his admission to hospital, so he had "left that day". He indicated a willingness to see the CSN to talk about his future and a visit in two weeks was arranged. There was an amount of social conversation, on football for instance. The CSN gave XX a telephone number to contact him if he wished to do so.
FFF informed Dr CCC's colleague, Dr ZZZ, in Dr CCC's absence, who advised him to leave a message with Dr CCC's secretary. Dr DDD in Ward Q was also informed of the appointment being requested.
On 20th July, the next day, FFF reported his visit in some detail in a letter to Dr CCC, with a copy to Dr Yyyy. The original letter bears a note by Dr CCC - apparently indicating concern, "make sure he's got an appointment to see me". XX's mother was very worried and on the same day she telephoned FFF saying that XX was sleeping better and was less irritable but expressing a worry that he had lost his job. He was remaining isolated in his room. She asked to see Dr CCC. She also attempted to get an appointment with Dr Yyyy, telephoning the surgery, but was told the earliest date available was 10th August. There was no indication that this was for an urgent matter, the surgery was very busy at the time and so the date fixed was not until after the tragedy occurred. Dr Yyyy indicated that if there had been any suggestion of urgency she would have been able to see Mrs X earlier, at the end of a normal surgery.
The family were worried about XX not settling at home. His father raised with him the possibility of finding independent accommodation, without any positive response from XX. A quarrel appears to have taken place on 6th August.
On 3rd August, some two weeks after his first visit FFF again called to see XX. He did so to attempt to administer the medication, to make a psychiatric assessment and to see if he could help generally. Again XX was very friendly. He explained that he had given up his job because it was not to his liking, but was confident he could get another. There was a discussion as to possible tensions within the family. XX's mother joined them and appeared to be somewhat flat in her responses, indicating that she felt that her son should start to get on with his own life. Her subsequent conversation indicated some real and long-standing tension in their relationship, so the nurse tactfully terminated the visit, having suggested that she and XX might care to discuss those problems with Dr CCC.
As a consequence of the worries caused by his visit the nurse phoned Dr CCC to tell her of the situation. At her suggestion he initiated with her secretary the possibility of an appointment for XX and his mother to see Dr CCC. It was fixed for 23rd August.
It was on the 8th August that Xx killed his mother and subsequently his half-brother. He left hand-written notes around the bodies indicating that he knew he was mentally very ill. He then went to the doctor's surgery and reported the killings; the police, who had been called, arrived and arrested him. His father was informed and left his work and returned home.
He has told us how difficult he found it. He was unable to get into the house, although he was provided with necessary clothes.
(i) Discharge from hospital
The procedures for discharge from Ward Q are apparently well established. XX was referred to the xxxxx Community Mental Health Team and a discharge report was prepared and sent to his G.P., Dr Yyyy which took some time to arrive at the surgery.
(ii) Community Psychiatric Nursing
Although the allocation of patients by the community team is informal - cases are discussed, some workers volunteer to take a particular case on to their caseload and others are allocated by their supervisor - it appears to combine professional judgement with some attention given to the personal suitability of the nurse. The seriousness or degree of difficulty determines the level of nurse allocated - Community Psychiatric Nurse (CPN) or Community Support Nurse (CSN). Mr FFF, an experienced nurse, indicated to his supervisor that he would be willing to take XX on to his caseload and as there appeared to be no particular difficulties or unusual circumstances this was felt to be appropriate. The discharge document had limited information on the medication he was on when he was discharged and indicated that he was non-compliant. His first task was to administer the next injection when it was due, and he arranged for a visit by telephone. Had there been fuller information available, allocation to a CPN might have been thought to be more appropriate.
The CSN appears to have done well in establishing a good and friendly relationship with XX. He also dealt with the refusal to take the injection in a professional manner, ensuring that Dr CCC was informed. His second visit to XX was to see if he would now accept an injection but also to retain contact. He was well received by XX, although he refused the injection. They had a friendly conversation. However, on this visit he found himself involved in a difficult and emotional conversation with XX's mother which, very sensibly, he drew to a close as best he could. He immediately informed Dr DDD of the outcome of this visit. XX had indicated he would be prepared to see Dr CCC again. The outcome of the first visit had been reported by the CSN in a letter to Dr CCC and he made further contact following his second visit.
The general failure to identify the complexity of XX's problem and pass on information so that an appropriate level of experienced community nurse was assigned the task of visiting was unfortunate, but in the circumstances FFF appears to have coped very well with unexpected difficulties. It is especially noteworthy that he continued to visit when he indicated that established practice might well have led to support for XX being terminated on the grounds of non-co-operation.
(iii) Response to emerging difficulties
There was plainly enough going wrong to indicate the need for a thorough and speedy review of the discharge. It is at present difficult to envisage a clear chain of responsibility and there appear to be few rules or accepted practices as to what should be done. Clarification is of particular importance where, as here, a job sharing system is in place.
Although the Consultant had overall charge, and was easily contactable, there is an obvious difficulty in obtaining a speedy review when there is indication that serious problems are arising. Decisions such as whether to terminate the involvement of the Community Nurse, to seek medical opinion from the G.P. or the Consultant appear to be dealt with haphazardly. If a junior community nurse is reporting considerable difficulties and a tense social background there appears no machinery to give priority to a full review of the problems that are being reported. Merely to note circumstances and slot consideration into the normal cycle of after-care may not always be adequate and it must be extremely difficult for a junior professional to secure more immediate action to consider the deteriorating situation he has encountered.
15. Nursing documentation should record the discharge process.
16. Action should be taken to ensure greater clarity of responsibility once an in-patient reverts to care in the community.
17. The front-line carer - CSN or CPN - should have, in addition to the normal process of reporting through his seniors, the power to initiate promptly a full review of circumstances which are causing serious concern.
18. The employee specification should set out the competencies required of the post holder and identify the appropriate grade.
19. The delegation of work should follow the appropriate competencies.
20. The quality of the discharge information passed to the community service should be reviewed to ensure that appropriate professional matters are routinely covered.
21. The Consultant should ensure that the patient's G.P. receives notice of the discharge as soon as possible and his medical and social details as necessary to ensure continuity of care.
22. A clinical supervision network should ensure that individual staff are fully supported.
23. The Trust should publish patient information leaflets on medication and ensure this information is promptly communicated to the patient and carers.
24. Patients in the community should not be removed from follow-up, on any grounds, without full consideration of the circumstances, involving all the professionals concerned.
25. It is important to strengthen the role of the Community Link Nurse with Ward Q so as to establish continuity of care compatible with the Care Programme Approach.
26. The practice of changing the Community Link Nurse every 3 months should be reconsidered.