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
| 27 July 1971 | xxx xxx (XX) was born. His natural father had, before then, left his mother. He has no knowledge of him. |
| May 1974 | His mother married Mr Peter XXX. XX was thereafter adopted. |
| 5 March 1976 | XX's half-sister [..] was born. |
| 1983 | XX's half-brother [..] was born. He was generally regarded as fond of [..]. |
| 1975-1987 | XX attended local schools from the age of four until he was sixteen. Nothing of concern to our inquiry occurred and he left at the appropriate time. He appears to have left school with 'average grades' in a number of CSEs. He had a reasonable relationship with others, but few friends. Towards his leaving he truanted increasingly but he was neither suspended nor expelled. He apparently shared interests in music and football with his friends. |
| 1987-1995 | YTS placement in a warehouse. XX thought the pay was low and left after six months. He felt he lacked the ability to become a van driver. |
| There followed a succession of factory and largely labouring jobs, all of short duration, the longest being 15 months. | |
| There was during this time no significant involvement with girls. | |
| Membership of TA for a year or so. Some indication of enthusiasm but did not shine. | |
| Increasingly spending time in solitary pursuits - cycling, running and walking in the surrounding countryside. | |
| He was registered with a local GP practice at xxxx, xxxx. | |
| It is a group practice with 4 doctors. There is no rigid allocation but XX and his family have largely been seen, since her joining the practice, by Dr Yyyy. | |
| 31 May 1994 | First consultation with Dr Yyyy. She saw that he had some emotional problems, associated with anxiety about physical health and referred him for counselling. |
| 19 July 1994 | First meeting with counsellor - AAA. |
| There followed weekly meetings with very occasional breaks for holidays or 'cancellations' and for his period in hospital, after which meetings were resumed. | |
| September 1994 | He was seen again by Dr Yyyy, in September 1994, when antidepressants were prescribed, and in October 1994 for general medical matters. There were no overt signs detected of a major mental illness at this stage. |
| October 1994 | Attacked at xxx xxxx Station by a group of young males. Afterwards he took a Bowie knife with him when jogging, for protection. He also changed pattern from evening to morning runs. |
| 25 May 1995 | Came to see Dr Yyyy who, because of symptoms she then elicited, referred him urgently to a consultant psychiatrist - Dr CCC. |
| 26 May 1995 | Dr Yyyy sent a referral note to Dr CCC. |
| 14 June 1995 | Seen by Dr CCC at [..] Clinic. He came alone, although Dr Yyyy had urged him to take someone with him. Instead he told his parents he was 'going to the dentist'. Dr CCC diagnosed schizophrenia and decided he needed assessment and treatment in hospital under Section if he did not agree. |
| XX asked that his parents be informed. Dr CCC asked the GP to do this. Admission to Ward 34 arranged. | |
| 15 June 1995 | XX, who had agreed to enter hospital as an informal patient, arrived alone at Ward 34. He was admitted by Staff Nurse EEE, who assumed the role of 'named nurse'. |
| Preliminary examination by Dr DDD, Senior House Officer (SHO) to Dr CCC, who was expecting him. She had no doubt that there were symptoms of schizophrenia. XX, though not keen, accepted medication. XX discussed at a multi-disciplinary meeting (MDM). Appropriate medication determined and provisional assessment made of liability to detention under the Mental Health Act should he seek to leave. | |
| 20 June 1995 | XX told staff he had received notice of dismissal from his work. Staff intervened and got his notice rescinded. |
| XX was prescribed Temazepam as required. | |
| 21 June 1995 | Seen by Dr CCC on ward round. |
| Weekend leave approved. Possibility of discharge rejected. Dr CCC sent a reasonably full report of her initial outpatient assessment at Long Eaton Clinic to Dr Yyyy confirming 'a severe mental illness' requiring treatment in hospital and saying that XX had come informally but would be assessed for compulsory detention should he change his mind. | |
| Consultant assessment entered in his medical notes. | |
| 22 June 1995 | XX's father came to pick up XX for weekend leave. His medication had been prepared and he was told to return on Sunday the 25th at lunchtime. |
| A review of XX's progress was made at a multi-disciplinary meeting (MDM) by Dr ZZZ, in Dr CCC's absence. Agreed to continue his care plan. | |
| 25 June 1995 | XX returned as requested. He had little to say to staff about his visit home but did indicate to a nurse that he had not got on well with his mother. He wished to discuss this with Dr CCC on her ward round on the 28th. |
| 26 June 1995 | XX was reported to have had sleeping difficulties. He had been prescribed Temazapam as required from 20 June. |
| 27 June 1995 | XX was 'allowed out' for the afternoon. It appears that a decision had been made for XX to be discharged 'in a few days time' with the setting up of the usual safeguards of after-care. (This decision was recorded in the nursing notes of 29 June.) |
| 28 June 1995 | Discharge considered for 29 June. Dr CCC spoke to XX's father at his request. He expressed considerable concern and spoke of hidden weapons and the discarding of tablets in a waste bin. XX was felt to be 'splitting up the family'. Dr CCC reported that she had told Mr XXX how important it was for the family to keep in touch with the hospital and the GP. This was apparently the first and only conversation with XX's relatives. Mr XXX indicated to the Panel that there had been a number of visits by relatives to see XX, which do not appear to have been noted. |
| Dr CCC saw XX and his father together when the discussion was continued more guardedly. XX admitted to not taking the pills but there was no discussion of the hidden weapons. | |
| The named nurse was not involved nor informed of this discussion. Dr CCC recorded progress in his medical notes. The Community Team were reluctant to see quick discharge. | |
| Depot medication started with test dose. XX had a disturbed night and was reported as 'wandering around'. Discharge intended on 29 June if no adverse reaction to medication. | |
| 29 June 1995 | Nursing notes indicate that Dr CCC had decided to change the intended 'discharge' to 'leave for a week' with the understanding that if all went well then on his return on 6 July XX was to be given a Depot injection and discharged. |
| XX was collected by his father and went home on leave. Father unaware of change to leave at that time. | |
| MDM confirmed the week's leave and discharge if no problems had arisen. | |
| 4 July 1995 | Community Mental Health Team informed of XX's impending discharge by the ward staff on standard referral form. |
| 6 July 1995 | XX returned, was seen by Dr DDD, had a further Depot injection and was discharged. He reported that there had been some difficulties but he had been offered his job back. Advised to see GP. |
| 7 July 1995 | The allocation was made by the Community Psychiatric Nurse (CPN). XX was allocated to FFF FFF, Community Support Nurse (CSN), who worked with Dr Yyyy's patients. FFF FFF took responsibility for liaison with XX. |
| 10 July 1995 | FFF FFF (CSN) telephoned XX at home to arrange the visit for an assessment and a Depot injection. |
| 13 July 1995 | Dr Yyyy certified XX fit for work. |
| 17 July 1995 | Brief period at work. Could not manage new duties. Left. |
| 19 July 1995 | Visit by CSN as arranged. Injection refused but XX promised to take the tablets. The visit went very well and was calm and relaxed. As well as advice being given to XX there was some general conversation on matters such as football in which both were interested. XX said that Sulpiride had helped his auditory hallucinations but firmly rejected the Depot injection. He reported that he had left his job. XX agreed to see Dr CCC and FFF FFF said he would visit again on 3 August. |
| 20 July 1995 | Notice of refusal of Depot medication sent by letter from FFF FFF to Dr Yyyy and Dr CCC and in her absence Dr DDD informed by telephone. |
| Mother informed CSN by telephone that XX was less irritable and sleeping better. He had given up his job, which was a concern, and was isolating himself from the family, keeping to his own room. | |
| Mother asked CSN for an appointment to see Dr CCC. FFF FFF included this request in the above letter. | |
| 22 July 1995 | Mrs XXX wrote to Dr Yyyy requesting an appointment to discuss XX. Made for 10 August. |
| 3 August 1995 | As arranged, FFF FFF visited again and Depot medication was again refused. XX indicated that the voices were less troubling, that he was sleeping better but was sleepy during the afternoons. He said the isolation was because he did not get on with his family. FFF FFF also spoke to Mrs XXX. |
| FFF again contacted Dr CCC about an appointment for Mrs XXX. Dr CCC noted and asked her secretary to arrange it. Letter confirming appointment for 23 August, received on 8 August, the day of the tragedy. | |
| 8 August 1995 | On this day XX violently attacked and killed his mother and younger half-brother. He then went to his GP's surgery and the police were alerted and took him into custody. |
| 6 March 1996 | XX appeared before the Nottingham Crown Court. He pleaded not guilty to murder but guilty to two counts of manslaughter on the grounds of diminished responsibility. After hearing medical evidence, Judge David Latham sentenced him to be detained under the Mental Health Act, without limit of time. |