In the pointless cycle of change, some things remain the same

Valdo Calocane’s killing of three passers-by on a Nottingham street raises some profound issues, though the primary focus for now must be on the trauma experienced by the families of his victims and others directly affected.  Events such as those which took place in June last year always remind me of the killing of Jenny Morrison, a colleague of mine for twenty years, in 1998. 

She had gone to check up on a young man in a south London hostel, where he had been discharged from our hospital not long before. He stabbed her more than a hundred times, believing she was a member of Combat 18, a neo-Nazi organisation.  The subsequent inquiry revealed that staff had not passed on how disturbed he was and that he had said she would be “a brave woman” to visit him, attributing his behaviour to his drinking.  Needless to say, his fellow-residents did appreciate the full extent of his illness. At no time had anyone thought to contact his mother who spent time with him regularly.  His concerning history, well-documented in reports from his previous hospital, was not taken on board by his new team, of which Jenny was a member.

However, as staff moved on once the intensity of the trauma had faded a little, the waters closed over the terrible incident and its key lessons were lost to institutional amnesia.  Clinical learning from other disturbing events – the killing of a nursing assistant on our secure unit by a new patient and that of Denis Finnegan in Richmond Park by a restricted patient who had been allowed some ground leave – also fell away in the atmosphere of blame and recrimination which followed.

The report into the last of these cases ran to more than four hundred pages but, if anything, had a negative effect on both morale and practice (the two are connected). This happens because staff, instead of having their practice sharpened by the two or three key clinical lessons which distinguish each case, feel ground down by a welter of recommendations leading to new, time-devouring procedures, the harvesting of yet more data and the futile rejigging of teams and service.

In the pointless cycle of change, which saps the energy of organisations, a few things remain the same. Reports into the deaths of Jonathan Zito at Finsbury Park tube station in 1992 and especially that of Nina Mackay, one of a team of police officers sent to arrest a man with untreated schizophrenia in Newham in 1997, tell you everything you need to know about how things go wrong.

Her killer had a long history of illness, characterised by a chaotic, nomadic lifestyle and escalating violence. He bounced between services and London boroughs with superficial contact with an army of peripheral professionals spread across a fatally fragmented landscape of what passed for support. Hundreds of decisions were made over time by people who had little idea of what it was they were dealing with. And those who did know what was going on – his immediate family and a diligent and tenacious GP – were, in the institutional mind – distant, marginal figures.

When you have not only worked in the field of mental health for many years but also looked after a close relative with serious challenges sometimes putting him at grave risk, you know only too well what many families go through. You will have cajoled the police relentlessly to intervene when the dangers became extreme – now much harder because of the misguided policy of “Right Care, Right Person”, wisely halted by Norfolk Police following the deaths of four people in their area. You will have tried to anticipate the crises and cock-ups which are a staple of mental health care, as it now is, and challenged the foolish decisions which so often undo progress that has been made.

There are no easy answers. New funding can actually lead to too much specialism which creates a fragmented, cellular service with wasteful wrangling across boundaries, as happened with New Labour’s many bright ideas in the 1990s. We need simple structures, with generic teams which are able to offer enduring continuity of care provided by staff who have the natural, personal skills to engage patients and their families fully.

Serious mental illness is not that difficult to treat, once the right medication is identified and provided in the context of a trusting partnership with patients: the drugs do work. The focus must be on the perverse systemic, cultural and organisational factors which subvert the talents of a highly motivated workforce and prevent staff doing what they come to work to do. And, above all, the hidden discrimination against high-stigma disorders such as paranoid schizophrenia, which attract far less support than the now wide range of low-stigma ones chronicled in social media, must be acknowledged and removed.