Inq1.
Ritchie/Clunis.
I am going to refer to the Inquiry reports, as above , under the name of the Chair and subject of the Inquiry ; and/or subsequently by abbreviation to both initials .
e.g. R/Cl.This Inquiry was the one which led to the mandatory Department guidance that subsequent tragedies should always be looked into by an External Inquiry .
The Inquiry about the care of Christopher Clunis was denied by the Minister of Health John Bowis , until the media presentation raised by the wife of the victim , Jane Zito , with concern about that level of care , convinced the UK government ( Secretary of State : Virginia Bottomley ) that public interest would be best assuaged by holding these Inquiries and publishing what they thought publishable , whenever a similar event arose in the future .
The Ritchie/Clunis Inquiry had as its remit , from what its fact-finding brief brought out , to look ahead and make general recommendations for improving the community mental health services .
It may be that this broad request led them to seem to under-emphasise aspects of care which were later more closely scrutinised and disclosed . The number of agencies involved , in different locality catchment areas , meant that the 'commissioning ' process - the plan determined by the various Health Authorities on purchasing the local service , is never examined . It follows that those who accepted the providing contract - HealthCare Trusts - are themselves never examined for what working practices they determined were necessary to deliver the commissioning requirement . The area neglected is aftercare contact and provision .
Little attention is given to a description of the medication regimes .The last receiving doctor ( who never got to interview him) in the last phase of his care , commented on the very low dosage Clunis was on when he was discharged from his last hospital admission , from Guy's Hospital .
A ' very low dosage ' would be quite likely to lead to relapse , leaving no margin for forgetting , or being tardy with replacement prescription . Cl. had attempted to get medication , and in fact sought medication from a new GP ( who had no knowledge of his previous official story ; a previous GP had put him off his list for over aggressive language and attitude ) and was given the sedative phenothiazine drug , chlorpromazine - basic for schizophrenia at that time .
This medication was found in his possession at his room , after the incident , but no information is available to make any conclusion that he had used the preparation . After a period without this preparation , restoring it would be sedative in side-effect , and might have stiffness side-effects , something not easily accomodated to when looking after yourself in the community . Clunis was a professional guitar playerHis stay at Guy's hospital was not long enough to establish that such a dosage worked in preventing the return of his illness . The in -patient stay in the Hospital immediately prior to his transfer to Guys , had retained him on a detaining Order , and had intended to establish him on a maintenance intra-muscular depot regime .
The problem of compliance with a sufficient medication regime is not raised directly in this R/Cl Report , but the Report did make the Recommendation towards legislation for a Community Supervisory Order .
After a subsequent Inquiry [Blom Cooper/Robinson] had strongly supported the notion of an authoritative supervision in gaining medication compliance , a Community Supervision Order was adopted .
In subsequent Inquiries where schizophrenia was the illness concerned , a lapse from a medication regime is noted as an important factor in the return of active , if concealed , schizophrenia - something which has led finally to the likelihood that there will be a Compulsory Community Treatment Order in any new Mental Health Act .
Another Recommendation of the R/Cl Inquiry, is that the Department of Health should come to clear guidelines about 'confidentiality ' - in respect of speaking to other observers about index behaviour . Subsequent Inquiries raise this as a continuing uncertainty , which has never been given authoritative clarity in the clinical situation - what to do when an index patient forbids exchange with an observer contact , perhaps a family relative or the family carer upon whom the index patient depends .
Professional carers have given this constraint of 'confidentiality' as an explanation as to why relevant information either was never sought by them , or was never available to them .