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

8. Medical management in outpatients
8.1 This section of the report deals with Mr Z’s management in the outpatient
department at Manor Gate CMHT. We focus on his last three years of care and treatment
and briefly consider the earlier period.
8.2 Mr Z was an outpatient for 16 years. He was usually seen by a staff-grade doctor.
The frequency of his appointments varied according to his mental state and the
assessment of his doctor. Latterly he had two appointments each year including with
locum staff-grade psychiatrist 1 and then locum staff-grade psychiatrist 2.
8.3 On four occasions Mr Z was also in the care of Manor Gate CMHT and regularly
seeing a CPN. He was allocated a key worker (CPN) in 1996, 1997, 1998 and 2005.
However, Mr Z was discharged from the CMHT because he either did not attend
appointments or said he no longer needed to see a CPN.
Management in outpatients between late 2007 and October 2008
8.4 Mr Z attended an outpatient appointment/CPA review with a locum psychiatrist on
4 April 2008. He told the locum psychiatrist he had been in trouble with the police. The
entry in the clinical records says ―said two incidents – of having trouble with police – last
year and January 2008 for possessing sharp weapons‖. The locum psychiatrist also told Mr
Z’s GP about this in a clinic letter soon after the appointment.
8.5 The locum psychiatrist discussed the case with consultant psychiatrist 1. Consultant
psychiatrist 1 proposed that Mr Z continue with his current medication and be followed up
in outpatients in September 2008.
8.6 Mr Z was next seen in outpatients in September 2008 by new psychiatrist, locum
staff-grade psychiatrist 1, whose note of the consultation says:
―past problems with police. Charged with GBH twice. Most latest is early this yr.
Fine £200 for 1 st one, caution for 2 nd one. Compliant with meds.”
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