An independent investigation into the care and ... - Hundred Families

said he had not lived there since 1997. Manor Gate had not updated their records and had
been sending correspondence to the wrong address 1 . Mr Z was living alone nearby. His
father confirmed that he and his wife saw Mr Z regularly but that his mood was low
because he was struggling to find employment. The next day Mr Z turned up at Manor
Gate CMHT and an appointment was made for April 2008.
5.33 In April 2008, a CPA meeting took place with a locum psychiatrist. Mr Z told the
psychiatrist about two incidents involving the police, one in 2007 and one in January 2008,
the latter concerning possession of a kitchen knife. The psychiatrist found no overt signs
of major mental illness and planned that Mr Z should continue with his current medication
and be followed up in six months.
5.34 A further CPA meeting in outpatients took place on 24 September 2008 with a new
psychiatrist, locum staff-grade psychiatrist 1. Mr Z said he had been in trouble with the
police in the past and charged with GBH twice, the last time earlier that year when he
received a caution. His mental state was described as stable, with no evidence of mood
disorder or perception abnormality. Locum staff-grade psychiatrist 1 planned that Mr Z
should continue with medication and be seen in six months.
5.35 Mr Z remained on CPA and locum staff-grade psychiatrist 2 took over his outpatient
care in October 2008. Locum staff-grade psychiatrist 2 carried out a six-monthly CPA
review on 12 March 2009. Mr Z said he was sleeping well and visiting his parents daily;
they were helping with his cooking. He had been taking his medication regularly and was
attending the Acton Training Centre 2 . Locum staff-grade psychiatrist 2 wrote in his letter
to the GP that Mr Z had no thoughts of harming himself or anybody else – no suicidal or
homicidal ideation and that he had no perceptual abnormalities. The care plan was for Mr
Z to continue with current medication. Locum staff-grade psychiatrist 2 arranged to see
him in a further six months.
5.36 Locum staff-grade psychiatrist 2 saw Mr Z in his outpatient clinic on 4 September
2009. Mr Z confirmed he was compliant with his medication and was experiencing no side
effects. Mr Z spoke of further incidents involving the police. He told locum staff-grade
psychiatrist 2 that in January 2009 he had been in a fight with someone living near his
1
Trust letters to Mr Z were routinely sent to his parent’s home. Fortunately Mr Z visited his parent
regularly so is likely to have received the letters.
2
Acton Training Centre is a training company offering training in ICT and basic skills.
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