WIFE KILLING ‘A TRAGEDY’ — (Somerset County Gazette)

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THE INDEPENDENT INQUIRY INTO THE CARE AND TREATMENT OF A PATIENT KNOWN AS X

SUMMARY OF EVENTS

Mr X was a retired university lecturer who moved to Cornwall on his retirement, where he and his family had spent many happy holidays.  He and his wife moved house several times and eventually settling in the Helston area, west Cornwall.

In October 2001 Mr X developed some physical health problems leading to hospital admission for investigations of gastric bleeding, caused by inflammation to the lower end of the oesophagus.  He apparently feared that he might have a malignant illness, which was eventually ruled out.  Following a serious disagreement, in which they discussed previous marital disharmony, he made a serious suicide attempt and was admitted to Treliske Hospital, Truro, with multiple cuts to his wrists, neck and abdomen, requiring emergency surgery.  During his stay in this hospital he tried to jump out of the window.  Following his recovery from his injuries and an assessment by the liaison psychiatry team, on 7 November 2001 he was transferred to Trengweath Hospital, the mental health inpatient unit at Redruth, to the care of Dr Jeremy Scott, Consultant Psychiatrist.

This admission was for about 13 days, following which he was looked after in the community by his wife and supported by a Community Psychiatric Nurse (CPN) and his General Practitioner (GP).

Unable to settle at home and becoming more unwell, he was readmitted on 1 December for a further 10 days and then discharged.  Sometime during the early hours of 21 December he attempted to strangle his wife and was readmitted to Trengweath Hospital.

During this third admission Dr Scott referred Mr X to a Consultant Psychiatrist for older people, requesting a second opinion as he gave the impression of developing early onset of an organic dementia, possibly of a vascular or Alzheimer’s in origin.  However Dr Steven Naylor, Consultant Psychiatrist for older people, was of the view that Mr X’s clinical presentation was not due to pre-senile dementia but more likely to be as a result of his anxiety.

He was discharged on 12 February 2002, again with support from Ms Helena Harper (CPN).  She visited him at home on 15 February 2002.  Although he was quiet, it was apparent that he became more anxious the longer the meeting went on.

On 17 February 2002 Mr X made a 999 telephone call to the police.  He was described as speaking “calmly and in normal conversation level”.  He said, “I have murdered my wife” and asked that a police officer be sent to their address.  Mrs X had suffered 14 stab wounds to the chest and abdomen.  Some of the wounds were inflicted after death.

A police surgeon and a psychiatrist assessed Mr X and concluded he was fit to be detained, and so he was remanded in custody.  On 25 March 2002, under Section 48 MHA 1983, he was transferred to the Butler Clinic, where he is still a patient.

Mr X pleaded guilty to manslaughter and on 2 August 2002 was sentenced to be detained on a hospital order under section 37 Mental Health Act 1983.  It was not seen to be necessary to make an order under section 41 Mental Health Act 1983 restricting his discharge from hospital.

MR X’S FIRST ADMISSION TO TRENGWEATH HOSPITAL AND DISCHARGE [excerpts]

9 November 2001  Mr X was described as feeling low (2/10), finding the ward intimating and noisy, and unable to concentrate on reading the newspaper.  The next day he was bright, cheerful and very conversational, allowing staff to help with his personal hygiene.  He was quoted as saying he would need a lot of help at home.  He continued to improve.

Dr Birch saw Mr X.  He told her that during the night he found the level of observation intrusive and hindered his sleep, but appreciated the opportunity to talk to staff.  He also found the ward intimidating but was ‘getting used’ to it.  He told her that he felt ‘shame’ at being so low as he had such a wonderful life and felt that he would not attempt to harm himself again.  He did not understand why the previous attempt happened and had he had someone to talk to, he wouldn’t have gone through with it.  Mr X was undecided about wanting to talk to his wife about his feelings.

His Care Plan was as follows

1. the level of observation was reduced to every 20 minutes
2. give regular night analgesia and lactulose
3. review sutures on Monday
4. start antidepressants – Citalopram

20 November 2001 Mr and Mrs X attended Dr Scott’s ward round. Mr X still appeared anxious and withdrawn and Mrs X stated that her husband found the ward rounds very stressful. Mrs X agreed to see the CPN. Mr X was given a week’s supply of Haloperidol, Citalopram, Lorazepam and Omeperazole, to be used as instructed.

…

MR X’S THIRD ADMISSION TO TRENGWEATH HOSPITAL AND DISCHARGE

20 December 2001  Mr X was seen in the outpatient clinic and was both agitated and distressed.  He was pre-occupied with morbid delusional ideas such as being tortured or burned to death.  Mrs X was very insistent that she could look after him at home, knowing that she could keep in touch with ward.  Dothiepin 50mgs was prescribed instead of Citalopram, and Diazepam 2mgs to be taken as necessary, up to four times a day.  Dr Scott wrote to Dr Dorrell:  “ …he is again very depressed and anxious but his wife is very insistent that she is able to look after him at home.  He is expressing irrational fears and at times he appeared rather confused so we may, in the end, have to readmit him to hospital.  However I do hope he may yet be able to settle and recover at home…”

Comment  – Ms Harper told us that Mr X refused to leave the room, or was not able to leave the room.  He stood in the corridor motionless and mute.  He was given some diazepam or lorazepam and after much coaxing he was transferred to Mrs X’s car who then took him home.  Ms Harper had not seen him like that before.  Mrs X appeared to make matters worse by telephoning family members and friends requesting them to speak to him.  He was so confused and did not appear to know what was going on.  Dr Scott has informed us that Mr X “ believed he was to be forcibly taken to Trengweath Hospital to be tortured and executed.” Dr Scott had not seen evidence of such psychosis during the previous inpatient stays.

We doubt that Mr X was able to give informed consent to the change in his treatment at this point.  The case notes do not record an explanation for his psychosis nor do they record a plan of investigation for the psychosis.  He was not prescribed any anti-psychotic medication.  We also have reservations about   the extent to which a clinician could successfully make a risk assessment at this point, given how irrational and aroused Mr X was.

Mr X was undoubtedly far worse than at the time of discharge.  In our view Mr X should have been admitted to hospital at this stage.  It is quite possible that either Mr or Mrs X would have objected to this plan, in which case an assessment under the Mental Health Act (1983) could have been initiated.  The nearest relative cannot block admission under Section 2 of the Act, which would have been the appropriate Section to use in the circumstances, allowing as it does for admission for assessment for up to 28 days.  Mr X undoubtedly had a mental disorder and there was a potential for serious risk, as evidenced by his very serious suicide attempt.  Clinical staff would understandably have reservations about the consequences of such an action on the therapeutic relationship with Mr and Mrs X, but paradoxically such a move might have brought into sharp relief the need to establish clear boundaries with Mrs X.

It has been suggested to the Inquiry panel that the threat of admission might have provoked serious medical problems such as a stroke or heart attack because Mr X had “ serious cardio-vascular disease.” In fact the medical notes explicitly exclude such disease.  In addition Dr Scott, in his medical report dated March 2002, refers to Mr X as having no health problems apart from his abdominal complaint and his mental health difficulties.

Clearly Mr X could not have been held against his will at the clinic.  If he refused admission he could have been allowed home without the threat of detention, so as not to scare him into any rash action.  In these circumstances the risks would justify a lack of frankness to the patient and carer.  An Approved Social Worker and the GP could then have performed a Mental Health Act assessment later at the patient’s home, following on from Dr Scott’s completed recommendation.  Assuming they were in agreement with the need for compulsory admission, Mr X could then have been taken to Trengweath.

Had Mr X been admitted at this stage, we cannot say with any certainty what might have transpired with regard to improvements in the accuracy of diagnosis,  a more effective treatment plan, and the ultimate outcomes in this case.  As it was, Mr X was sent home, apparently on his wife’s insistence, and his medication was altered.  Changing his medication was appropriate, but a phased withdrawal of the Citalopram would have been advisable.

21 December 2001  The Police and an ambulance crew attended Mr and Mrs X’s home at 06.39hours as Mr X had attacked his wife earlier, trying to strangle her.  She hid in the toilet as instructed by the police.  When they entered the house they found Mr X holding onto the toilet door handle, staring at his hands.  Further police assistance arrived at 06.54hours; Mr X was restrained and wrapped in a blanket as he had no clothes on.  He appeared passive and in a trance unable to respond to anything.  Mrs X was released from the toilet and examined for any injuries.  None were visible.  Mrs X told the police officers that the previous night she and her husband had had heated discussions, about their previous marital difficulties, which were continued that morning.  She stated that she did not believe that her husband would hurt her, and only locked the door when the police instructed her to do so.

Mrs X wanted her husband to go to Trengweath Hospital to have his medication reviewed and so the ambulance crew took him there.  During the examination Mr X was worried about being tortured by his wife and daughter.  He also worried about being burnt, and that his other daughter wanted to harm him.  During the duty SHO’s assessment he made contradictory statements about being in Trengweath Hospital, saying –“not safe here – why should I be risk anywhere.  I’m mad – I’m not mad”.  Mr X admitted that he was feeling anxious “ because my wife and daughter are coming to kill me”.  His speech was quiet and repetitive.  He scored 16/30 on the mini mental state examination (MMSE)  – unable to do tasks which should have been easy for him.  During the physical examination Mr X made no verbal responses, and could not be persuaded to leave the clinical room without physical help.

A history was taken from Mrs X.  She stated that Mr X was “terrified he would be put back in hospital again”.  She would not leave him and agreed that his depression was increased after his discharge.  Mrs X also told the doctor that, in her opinion, when in Trengweath Hospital Mr X had said the Citalopram was working so that he could go home.  She went on to say that he now had delusions,  thinking he was “ESN and that he was a psychopath” without knowing what it meant.  He thought that their youngest daughter was dead and that other family members were going to torture him.  The SHO concluded that the diagnosis was, “?severe anxiety with depression”.  Dr Scott had previously prescribed Prothiaden, which was to be continued, and 10 minute observational checks were started.  The following day Mr X took his medication and settled, although he remained very disorientated and confused.   At this time Dr Maggie Hand, Medical Director, was conducting a survey of patients who were re-admitted as an emergency within 90 days or less having previously discharged.  This was in response to a National Performance Indicator to evaluate performance.  The Trust had a high emergency re-admission rate and the survey was seen as a way of identifying which service developments were required to decrease the number of re-admissions.  The completed form was returned to the Clinical Audit office and no copy was kept in the patient’s notes because of individual confidentiality and the need for anonymity.  The form was divided into five sections as follows: 1. what care did you receive at home since your last admission? 2. how helpful did you find your last admission? 3. why do you think you needed to come into hospital on this occasion? 4. what other services or care, if it had been available, would have been preferable to hospital admission or might have prevented admission? 5. is there anything else you think it would be useful for us to know about?

Mr and Mrs X completed such a form and they kept two copies as part of their own note keeping.  One copy had Mr X’s comments only and the other had his original comments with annotated notes we presume by Mrs X.  In the completed section on care at home, the CPN, outpatients, out of hours service and GP contact had been ticked.

On the form Mr X described the previous admission (following the attempted suicide), as “ my absolute nightmare” and annotated against it was  “the manner of (name)’s last admission so terrified him he was unable to speak to me at all. The next morning, he became more and more depressed, losing weight and started compulsive teeth grinding. Unknown to me he persuaded the nursing staff he was getting better and told Dr Scott the drugs had started working.  (name) was suffering from the delusion that I was trying to kill him.  He then tried to strangle me” Mr X described his reason for admission on this occasion as  “ I wanted to speak to a doctor about my medication as my wife had done the previous week.  I did feel very depressed but not in any imminent danger.  I would have been happy to see a doctor next week”.   He went on to write against question 4  “ a doctor to consult to speak to over the phone to discuss medication and change it if necessary.  Too long between consultations”  and against question 5  “on my notes I had asked to be seen with my wife present.  I was having difficulty with social interactions.  The on-call doctor terrified me and ordered my wife to leave the room.  I was worried about what I would say to the doctor and we had been told she could stay with me previously.  When I was asked if I would be seen alone, and I was too frightened to speak, Richard said that if I said nothing, that would mean yes.  After my wife had left I felt coerced into agreeing to a witness statement with David and Heidi.  I felt it was against my will.  I was then under the impression that I would be there for life.  Later David told me I would be in Trengweath Hospital for a very long time and at the very least months”

Comment  As this was a confidential questionnaire this information was never shared with the staff in this format.

23 December 2001  The SHO spoke to Mrs X and her daughter, telling them that Mr X was settling although he had been observed in his bed area trembling, feeling unsafe and at risk of being attacked by his wife.  These symptoms were explained as part of the depression and anxiety rather than as the result of any physical problem.  The SHO thought it would be useful to have an EEG and to bring forward the CT scan.

24 December 2001  Mr X was seen by Dr Birch and appeared unable to talk and only able to follow simple commands.  She ordered blood tests and for his fluids and food intake to be increased.  He didn’t know that it was Christmas Eve and that the following day was Christmas Day.  However he did recognise a staff nurse who had not been on duty for 10 days.

25 December 2001.   Mr X was visited by his family and ate the sandwiches they had brought in for him as he was still reluctant to eat the hospital food.  He brightened up as the evening wore on, ate his supper and enjoyed watching television.

26 December 2001  Mr X was found wandering around the sleeping area, saying he had lost his clothes.  He was in fact looking in the wrong space.

1 January 2002  Mr X was still having periods of confusion but these had become less in the last few days.

2 January 2002  Mr X kept an appointment at Treliske Hospital accompanied by his wife.  When Mr X returned to the ward he was agitated, finding it hard to concentrate, and was confused about his washing and clothes.  Because of his confusion the staff found it necessary to help him have a bath that evening.

3 January 2002  Mr X attended Dr Scott’s ward round.  He expressed no feeling of paranoia although still felt ‘panicky’.  He gave a good account of what he had done the day before and his memory seemed good.  His wife said he was suffering from the same stomach cramps that he had experienced before, in the two years since she had had breast illness.

Later that night he was seen by Dr Birch, as he collapsed whilst retching in the toilet.  His pulse was 100 and regular, blood pressure 150/60 and there were no neurological deficits.  He was very distressed saying “ I haven’t been telling the truth.  I’ll never get out of this”, expressing guilt about the past and secrets he had never told anyone.  She concluded that he had a gastro-intestinal infection and nausea following anxiety.  Haloperidol 5mgs was given and he was encouraged to rest in bed.

Comment  The family were of the belief that Dr Birch thought these symptoms were the same stomach cramps he was experiencing due to his anxiety, but this was clearly not the case from her records.

4 January 2002  Mrs X telephoned to express her concerns about her husband’s presentation.  She felt that he presented as “quite well” at the ward round but to her he was confused at times and “obsessed” about his clothing, believing he didn’t have any.  He had cried before the ward round, and she felt he was not getting better.  Mrs X queried whether the medication was making him confused and asked that she should be present at the ward rounds, so that she could provide her perceptions of her husband’s well being and presentation.  The ward was notified that the EEG was arranged for the 16/1/01.

5 January 2002  The duty SHO was called as Mr X apparently collapsed in his chair shortly after his wife had left.  He had not been feeling well for a couple of days with abdominal aches.  He said he was a coward, had not been totally honest with his family as he had wanted to die because his wife might leave him.  She had threatened to do so before.  His speech was slow, rational and coherent.  His mood was depressed and anxious .

with suicidal thoughts.  The diagnosis was severe depression with anxiety.  The doctor spoke to Mrs X who told him that she thought the Diazepam and Lorazepam made him worse and confused.

6 January 2001  Mr X remained unwell and more anxious and confused, and was advised to rest on his bed away from his wife.  He slept, and on waking felt better, but when he returned to the day area and his wife he became confused and anxious again.  Later that evening he was reluctant to take his medication, saying that his wife had told him not to take it as it made him worse.

8 January 2002.   Dr Birch saw Mr X.  He was no longer vomiting but had some diarrhoea.  He knew which day it was but didn’t manage to count beyond 51 before becoming anxious.  Mrs X was interviewed and she again said she thought the diazepam was making him confused.  She talked at great length about Mr X’s childhood.  She was unable to give an exact history and spoke in a long monologue presenting as distressed and anxious.

The Care Plan was reviewed as follows 1. continue the medication 2. refer …..for opinion re. Cognition 3. no leave at current time. 4. The CT scan was normal

9 January 2002  Dr Birch saw Mr X alone.  He had had his breakfast and had had no further abdominal pain or vomiting.  He made good eye contact with good speech, if a little slow.  At times he found it difficult to answer questions, and was anxious about saying the right things when asked how he was feeling.  He feared being incarcerated and split up from his family.  He didn’t feel his memory and cognition was improving and on occasions he complained he couldn’t remember what day it was, or what the correct route was when his wife was driving.

10 January 2002  Mr X went out with his wife in the afternoon.  Dr Scott referred Mr X to Dr Steven Naylor, Consultant Psychiatrist for older people, requesting a second opinion.  He outlined Mr X’s medical history to date, including the attempted suicide, which seemed to be linked to “ a depressive illness and marital problems”.  He went on to say  “……fortunately no sinister pathology was found and his symptoms were attributed to some benign inflammation in the lower oesophagus.  He seemed much relieved when he learned of the results of his investigations and he went home in good heart and with apparently much improved marital harmony although the psychodynamics of family relationships seem extremely complicated.  Both Mr and Mrs X are very anxious and their interactions are difficult to understand and probably much influenced by a wide range of fears some of which seem to be illogical or unfounded…… For a short time Mr X did quite well at home with a CPN and antidepressant medication (Citalopram).

However before Christmas he re-presented at the outpatient clinic in a very disturbed state in which he appeared to be deluded and to have lost his grasp on reality.  He behaved in an agitated state, pacing up and down and fluctuating from being almost mute to shouting loudly….  He calmed down with some Diazepam but later at home attacked his wife and had to re-admitted to Trengweath.  He had since then shown varying degrees of disorientation and cognitive impairment.  Initially he was grossly disorientated and on Christmas Eve he did not have any awareness of the date or the season.  Quite rapidly he regained much of his orientation and the subsequent fluctuations have been less marked.  At his best he is fully orientated and his short-term memory is reasonably good though still impaired.  However he appears to function well below the sort of level that would be expected in view of his background as a university lecturer in mathematics…… He also shows emotionally lability and incongruity and his mental state is generally unstable.  The whole picture is strongly suggestive of an underlying organic disorder possibly of vascular aetiology leading to a presentation of early dementia with relatively lucid intervals.  His

depressed mood and his severe anxiety clearly played some part in his impaired functional capacity but I am not so sure that we can attribute the symptomatology purely to a depressive pseudo- dementia”.

11 January 2002  Dr Birch saw Mr X.  He was still anxious at times and still experiencing poor memory, misremembering a previous conversation the day before with Dr Birch.  He scored 26/30 on the MMSE.  He enjoyed going out for lunch with his wife and they both requested to have home leave over the next weekend.  He was sleeping well and so diazepam was reduced to 1mgs.

14 January 2002  Mr X telephoned his daughter and was heard crying, presenting as anxious, indecisive and confused.  In discussion with Mr David Taylor, (S/N), he stated he did not want to be separated from his family.  Mr Taylor told him that as an informal patient he could go home the following day.  He stated he was physically unwell and needed to be in hospital.

15 January 2002  Mr X attended the ward round.  Dr Scott spent considerable time with Mr and Mrs X.  Mrs X felt that her husband should have a sigmoidoscopy and or a colonoscopy as she was concerned that he might have bowel cancer with brain metastases.  She also thought he had a testicular lump.

Comment Mrs X had already been given the results of the CT scan by Dr Birch, which revealed no abnormality.

Mr X was seen later on the ward when he expressed concerns that he might be sectioned and therefore never leave the ward.  He was reassured that this was not the case.

16 January 2002   Mr X had an EEG at Treliske Hospital.

17 January 2002  Mr Robin Gordon, occupational therapist, saw Mr X.  He was also seen and examined by Dr Winters, SHO, prior to referral to Dr Levine, Consultant Physician, because of Mrs X’s concerns about the possibility of her husband having a testicular lump.  Mr X was very anxious that he might be physically ill.  The EEG results showed nothing of any significance.  Later in the day he went out with his wife.

18 January 2002  Dr Steven Naylor interviewed Mr X to provide a second opinion of his confusion and poor memory.  Dr Steven Naylor interviewed him.  Dr Naylor concluded that his symptoms were consistent with severe anxiety disorder/panic disorder, exacerbated by antidepressant introduction, with episodes of dissociative cognitive impairment.  He wrote the following treatment plan 1. that his current antidepressant (Dothiepin) be reduced and withdrawn, and later if needed Imipramine (a different antidepressant) could gradually be introduced. 2. Use Lorazepam or Clorazepam for trial period to control panic as clinical test of extant anxiety is causing symptoms. 3. Dothiepin reduced to 50 mgs.

20 January 2002  Mr X still very anxious, quite inarticulate and concerned that he had not made sufficient progress since admission.  He needed much persuasion to take his medication.

22 January 2002  Mr X attended Dr Scott’s ward round and presented as anxious and distressed at times.  He had spent time out of the hospital with his wife.  Mr X’s antidepressant medication was reduced.  The EEG showed signs suggestive of early stages of dementia.  His wife told Dr Scott that prior to his admission her husband had taken St John’s Wort, which made him worse.  On this occasion, Mrs X presented as ‘very dramatically distressed’

23 January 2002  Dr Scott wrote to Dr Naylor:  “…… I would certainly agree there is a large functional overlay arising from his severe anxiety.  His wife describes his pre-morbid personality as confident, self-assured and gregarious and it would appear that there was probably an absence of dissociative phenomena until very recently.  I wonder, there fore, if there is a co-existing organic component contribution to the psychopathology even though the recent improvement in his orientation and short term memory is sufficient to enable him to perform well during testing.  Our suspicions are supported to some extent by the EEG report which indicates diffuse changes consistent with possible mild dementia….”

24 January 2002 Mr X spent time painting in the activity room and according to Mr Gordon was more relaxed.

25 January 2002  Dr Birch telephoned Dr Levine’s secretary to ascertain when Mr X’s appointment would be.  Dr Levine was on holiday and would see the referral on his return.  Mr X was very confused and unable to string together a sentence which made any sense.

28 January 2002  Mrs X anticipated seeing Dr Naylor, but had not shared this information with the staff and, as Dr Naylor was not due on the ward that day, she was unsuccessful.

29 January 2002.   Mr X did not attend Dr Scott’s ward round and so Mrs X was seen.  She told Dr Scott that Mr X was improving in his cognition since the Dothiepin had been stopped but that he was still anxious.  Mr X had a strong belief that the police would arrest him when he went home.  She inquired about the appointment with Dr Levine.

30 January 2002  Mr Bernard Kearney, Team Leader, had a long conversation with Mrs X about all her concerns since Mr X had been admitted.  During the conversation it seemed that her concerns appeared to have been resolved.  Mr X remained anxious.

31 January 2002  Mr X spent time in the activity room revisiting his computer skills with the occupational therapist.

1 February 2002  Mr X commenced two days leave from the ward.

3 February 2002  Mr X returned from leave and both he and his wife reported that it had gone well.  Mr X had cleaned the car and cooked meals.

5 February 2002  Mr X attended Dr Scott’s ward round and he requested to have more home leave as well as extra doses of Lorazepam.  Mrs X was pleased with his progress, though asked whether it was possible that Mr X had encephalitis.

8 February 2002  Mr X returned from leave to be interviewed by Dr Birch, who had a long discussion with him about his admissions.  He was given six days medication and told to return in four days time for the ward round.

12 February 2002   Mr X returned from leave to attend the ward round.  He was fully orientated and reasonably cheerful.  He was sleeping well and had a good appetite.  He was active at home, gardening and visiting friends.  He was discharged from the ward to be followed up by the CPN.  His medication was prescribed as Lorazepam 0.5mgs twice daily and could be omitted on the days that he felt relaxed.  Mr X agreed to see a therapist for massage and relaxation classes.

Dr Scott referred Mr X, as a private patient, to Dr McClean, Consultant Neurologist, for a further opinion of his physical health as Mr and Mrs X had requested an appointment.  He informed Dr McClean about the EEG and CT head scan.  He went on to say  “the EEG results lent some weight to the possibility of an organic dementia but subsequent clinical progress has been encouraging and Mr X now shows good recall for recent events and he is once again fully orientated.  I wondered if perhaps the EEG abnormalities might have been due to some reversible inflammatory process and I had in mind repeating the EEG in about six months to see if any significant differences had occurred in that period.  Mr X and his wife would be most interested to hear from you on your thoughts on his EEG and I am sure they will be most appreciative if an opportunity to talk to you about this matter on a private patient basis could be offered”.

13 February 2002  Dr Sarah Ashley, SHO to Dr David Levine, saw Mr X, as Dr Levine had seen him previously and diagnosed ‘irritable bowel syndrome’.  She recommended a CT scan and paracetamol tablets for the pain.  There was no plan to see Mr X in the clinic again.  Dr Birch completed the discharge prescription form, which was faxed to the GP.  Mr X’s medication was  1. Lorazepam 0.5mgs twice daily to be reviewed in 2-3 weeks 2. Omeprazole 20mgs daily 3. Asprin 75mgs daily Dr Birch also noted that he had had a poor/adverse response to Citalopram/Dothiepin.  He was given an outpatient appointment for three weeks and was to be visited by Ms Harper CPN.

15 February 2002  Mrs Harper, CPN visited Mr X at home.  He was quiet during the meeting and Mrs X did most of the talking, mainly complaining about his treatment and in particular, not receiving the EEG results and not knowing why Dr Naylor was asked to give a second opinion.  Mrs X had stopped Mr X’s medication two nights previously and so was advised to recommence as prescribed, 0.5mgs Lorazepam in the morning and again in the evening.  Mr X was referred to an anxiety management group when there was a vacancy.

17 February 2002  The Police received a 999 call from Mr X at 08.47 hours.  He stated that he had murdered his wife.  She had multiple stabs wounds.  When the police arrived, the front door had been smashed with a mallet, which was in the kitchen.  Mr X was arrested on suspicion of murder and taken to the police station.  Mr Rob Waring acted as the Appropriate Adult, and later that evening Dr F Lehmann-Waldau, Consultant Psychiatrist, conducted a mental health examination.  As a result Mr X was considered unfit for interview but fit to be detained with 24 hour one to one observations.