REPORT OF AN INDEPENDENT INQUIRY ... - Hundred Families

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10. On 26th February 1997, a Discharge Summary was written by Dr Sarah Evans, Dr Bamber’s
Senior House Officer, to a Dr Alleright whose address was given as The Surgery, Burgess Road,
East Ham, London. Dr Bamber said that he assumed the GP’s name was given to Dr Evans by
Chandran or his cousins. We had hoped to interview this GP as part of our investigation but the
enquiries made on our behalf revealed that the North East London Strategic Health Authority had
no record on its database of a GP with this name and, although there is a GP surgery at 27 Burgess
Road, we learned that there has not been a Dr Alleright working there. One possibility that has
occurred to us is that this was in fact intended to be a letter to Dr Alagrajah but we doubt whether
that is right. The Discharge Summary was not in Chandran’s GP records. We only found it in the
records we received from Canterbury & Thanet Community Healthcare Trust.
11. The Summary recorded a diagnosis of bipolar affective disorder, medication on discharge of
Haloperidol 3mgs tds “to reduce to 1.5 mgs tds after 5 days and then to be reviewed and stopped
as appropriate” and Procyclidine 5mgs tds and ended with the following request:
“We also discussed with him before discharge about starting Lithium and I should be grateful
if when he registers with you, you would refer him to the local psychiatrist for consideration
of Lithium therapy.”
12. In fact, Chandran registered as a new patient at The Market Street Health Group, 52 Market
Street, East Ham, London. On 18th February 1997, he attended the surgery where it was noted
that he had been in St Martin’s Hospital. This was recorded as being a psychiatric hospital. His
diagnosis was “manic depressive psychosis”. His medication was recorded as being Procyclidine
and Haloperidol. He was described as not being known to Social Services. We do not know
where this information came from, possibly from Chandran himself. It does not seem to us that
it can have come from the Discharge Summary since that is dated 26th February 1997, i.e. eight
days later, and the Discharge Summary was not filed in his GP records.
13. On 20th February 1997, Chandran was seen again at the surgery and was said to be going to India
on 23rd February 1997. A note was made “Needs to see psychiatrist”. However, we have seen
no evidence of a referral at this time. Chandran went to India with Mrs Ramkrishnan and was
there for about five months. There, he again appears to have had contact with a psychiatrist.
Chandran told us he had not worked or done anything and he felt a failure here. Sujita Trousdale
suggested that he should stay in India because it was easier for the family to find somebody to
look after him there whereas, in England, everybody who might have looked after him was
working. Nonetheless, Chandran did return to England.
Comment
The above chronology of events demonstrates that Chandran gradually became ill over a
number of months necessitating in-patient admission in January 1997. In other words, that
relapse was insidious and took place over a number of months, probably from February
1996, with blunted insight being an early feature but with a prodrome of Chandran
knowing something was going on in his head and looking for a medical explanation for this.
By January 1997, a potentially fatal drama had unfolded at his aunt’s house although Mrs
Ramkrishnan did not want to tell the police about it, despite being advised to do so by other
family members.