REPORT OF AN INDEPENDENT INQUIRY ... - Hundred Families

The treatment plan made for Chandran was an adequate one but there were no
mechanisms then in place for monitoring a patient’s progress against the plan in terms of
patient or indeed service accordance, which is plainly not a sufficient response. The
practical effect of this was that when Chandran failed to attend outpatient appointments,
his relationship with the psychiatric service ceased. Thus, Chandran’s contact with Social
Services ended in February 1992 and effectively ended with the specialist psychiatric
services in June 1992. On 23rd June 1992, he went to see Dr Feldman in her outpatient
clinic but he did not keep his subsequent appointments. He appears to have maintained
some contact with his GP surgery because he was issued repeat prescriptions but, as we
have already explained, it is possible that he did not in fact have any direct interaction with
a doctor there.
(2) We could find no evidence of any consideration being given by anyone involved in
Chandran’s care as to the difficult relationship which existed between him and his father.
The serious nature of his attack on his father and the undesirability of the two trying
effectively to act as co-carers were not issues which were confronted. In our view, it is
possible that this was because the situation was not viewed as unusual. In saying this, we
have in mind Dr Feldman’s observation that it was quite a common scenario for her to
encounter fathers and sons living together and fighting.
(3) In addition, we found no evidence that the nature of Chandran’s illness, including the
potential for recurrence, and advice as to how to manage his illness and how to access help
in the event of a recurrence, was discussed with any member of Chandran’s family or with
Chandran himself. To the extent that no key carer for Chandran was identified, there was
some practical difficulty to giving such advice. However, any such difficulty was by no
means insuperable. The practical routes for return to the mental health services (other than
via a GP) could and should have been made clearer to a family member and, indeed, to
Chandran himself.
30. Sujita Trousdale and Biju Ramkrishnan gave evidence that Chandran was well for a long time
after his admission to Goodmayes Hospital. He did various jobs which were described to us as
“odd jobs”, for example working in shops, and was also studying. He studied at Newham College
of Further Education gaining a BTEC First Diploma and National Diploma in Art and Design.
He also became involved with the “Guardian Angels” and patrolled the underground and streets
in the West End of London with them. He had a considerable amount of contact with various
members of the Ramkrishnan family who understood that he was continuing to be prescribed
Lithium Carbonate. In fact, looking at his GP records, it appears unlikely that he was prescribed
Lithium Carbonate after 3rd September 1993. On 3rd July 1995, it was noted in his GP records
that “Now he is free from psychiatric problems”.
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