REPORT OF AN INDEPENDENT INQUIRY ... - Hundred Families

6. In summary, the Internal Inquiry made four recommendations:-
a) Consideration should be given to enhancing the resources available to patients presenting
with psychotic illnesses in the early stage of those illnesses, either via a formal Early
Intervention System or the individual practices of Community Mental Health Teams.
b) All formal assessments of a patient should be disseminated to the relevant community mental
health team for that patient and his/her General Practitioner, and formal liaison should be
established by all community mental health teams with the police.
c) The ready and quick availability of psychiatric assessments should be a priority of
community mental health teams with regard to court cases, police contacts, GP surgeries and
family homes. Experienced nursing, social or medical staff should be available to make
assessments at times when individuals present with active symptoms of mental illness.
d) Regular agreed communication, co-operation and joint training should be undertaken with the
police.
7. Given the circumstances of this case, it was recognised that, in addition to the Internal Inquiry,
there had also to be an independent review of Chandran’s care and treatment. The National
Health Executive Circular “Guidance on the discharge of mentally disordered people and their
continuing care in the community” HSG (94) 27 states that, if a violent incident occurs involving
somebody who has had contact with mental health services, it is important not only to respond
to the immediate needs of the patient and others involved but in serious cases also to learn lessons
for the future. Paragraph 34 of the circular provides that:
“In cases of homicide, it will always be necessary to hold an inquiry which is independent of the
providers involved.”
8. Accordingly, this Independent Inquiry was jointly commissioned by the North East London
Strategic Health Authority and the Social Services Department of the London Borough of
Newham.
Terms of reference
9. The terms of reference for the Independent Inquiry are dated 27th September 2002 and are as
follows:
1. The Inquiry will examine all the circumstances surrounding the treatment and care of
Chandran Sukumaran, and in particular:
1.1. The quality and scope of his health and social care and any assessment of risk;
1.2. The appropriateness and quality of any assessment, care plan, treatment or supervision
provided, particularly having regard to
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