REPORT OF AN INDEPENDENT INQUIRY ... - Hundred Families

5. It was clear that information about Chandran was available from different sources and yet not
collated adequately so as to provide a complete picture. His medical records were held in a
number of different locations and much relevant information about him was not known to any
professional involved in his care at all. If the information about a service user is of a poor quality
or incomplete, there is a very real possibility that important information will not be available to
those who need it and that risks which might be managed will be missed. An incomplete
assessment of the risk of violence to others may provide false reassurance to family and friends
or, on the other hand, unfairly and inaccurately label a service user as violent.
6. The following list demonstrates the nature of the information which ought to have been gathered
from various sources and assimilated and ought, in our view, to have informed the decisions as
to whether Chandran needed access to mental health services and whether help was needed for
his family.
6.1 His childhood which had in many respects been very troubled. For example, we have
described earlier in this report how his mother and his aunt had committed suicide in India.
6.2 The nature of his relationship with his father who was often violent towards Chandran.
6.3 Some understanding as to the reason for his admission to hospital in India in the later part of
the 1980s when he was still very young. Although the Inquiry Panel doubts whether much
information about the detail of this admission would have been learned, Chandran’s family
were able to provide some relevant facts.
6.4 The psychiatric assessment by Dr Orton in April 1990 including Dr Orton’s view that
Chandran needed psychiatric assessment over a period of time. Such an assessment did not
take place because Chandran was discharged from the psychiatric outpatient clinic when he
failed to attend the appointments he was sent.
6.5 His inpatient admission to Goodmayes Hospital in January 1991 which included his detention
under Section 3 of the Mental Health Act 1983. This admission was preceded by Chandran’s
being frequently violent towards his father, allegedly threatening him with a knife and
destroying windows and furniture at the flat they shared.
6.6 His subsequent failure to attend outpatient appointments at any time other than on 28th
January 1992 (when the purpose of his visit to Dr Feldman was for a report dealing with his
capacity to give instructions to solicitors in relation to a personal injury claim) and on 23rd
June 1992 and 23rd July 1997. In total, he missed seven outpatient appointments, i.e. on 18th
June 1990, 16th September 1991 (i.e. immediately following his discharge as an in-patient
from Goodmayes Hospital), 27th March 1992, 25th September 1992, 1st December 1992 and
in September 1997 and April 1998.
6.7 The lack of any adequate monitoring of the Lithium Carbonate prescribed on his discharge
from Goodmayes Hospital.
6.8 The damage he caused again to the flat in Corporation Street in 1996.
6.9 The incident involving Mrs Ramkrishnan in December 1996 when he had destroyed her
devotional artefacts and led her to believe he was going to get a knife with which to threaten her.
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