REPORT OF AN INDEPENDENT INQUIRY ... - Hundred Families

By then, there was a history of illness extending back almost ten years with, as we assess
the history, three major relapses. We do not consider this information was fully available to
those caring for Chandran at St. Martin’s Hospital. This was partly because his earlier
notes did not arrive at the hospital so neither the fact of the admission to hospital in India
nor his subsequent non-compliance with his medication regime, nor the full extent of his
earlier admission to Goodmayes Hospital and the background leading up to it were known.
It was also in part because, as far as we can ascertain, there was no discussion between any
member of Chandran’s family and the staff at St Martin’s Hospital about his illness nor
about the plans for him on discharge. Although we do not know whether Mrs Ramkrishnan
would have spoken about the incident involving her in any event, given her unwillingness
to report it to the police, we do know other family members were prepared to speak about
Chandran’s illness because they have spoken to us about it. Additionally, when we spoke to
Chandran, his present social worker told us that a lot of relevant information about him
had now been learned from the family.
Thereafter, in our view, the proper conclusion following this sequence of events is that the
aftercare planned for Chandran, namely the consideration by a psychiatrist of the
indication for an ongoing mood stabilizer, was not worked through fully at that stage. In
real terms, nothing for or against the use of ongoing mood stabilizers was communicated to
the new GP in London by staff at St. Martin’s Hospital because of the error in the GP’s
name and address. By the same token, it also seems likely that a copy of Dr Evans’
Discharge Summary was not sought by the general practice with which he registered in
London although the practice was aware he had been admitted to St Martin’s Hospital.
We think this is likely because there was no copy of it in the GP records with which we
were provided.
It will be seen later in this chapter that Chandran was in fact referred back to secondary
care but this did not come about as a result of Dr Evans’ request that there should be a
referral to psychiatric services. On that subsequent referral, a copy of the Discharge
Summary was not sought. We consider that Caroline Godleman rightly accepted in the
course of her evidence that it should have been.
The outcome of this failure to communicate was that detailed information about the
Canterbury admission and the plan for discharge was never amalgamated with
Chandran’s medical notes in London. Similarly, his family had no information about the
admission and the discharge plan. This period of in-patient care was therefore isolated
from other information and, whilst it was known that Chandran had been admitted to St.
Martin’s Hospital, the reasons for that admission and details of it appear to have been
largely unknown, as was Dr Evans’ request for a referral to a local psychiatrist.
In those circumstances, there was no actual transfer of Chandran’s care as anticipated by
the CPA and an opportunity to provide him with continuity of care on discharge from St
Martin’s Hospital was lost.
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