REPORT OF AN INDEPENDENT INQUIRY ... - Hundred Families

We believe that appropriate CPA planning ought to ensure that relatives of patients are not left in a
situation where they simply turn to the police for help, but that they know the action they need to take
to respond to a crisis and what to expect of the professionals who will be involved 1
. We have concluded
that the promotion of both patients’ and carers’ awareness of how to get help from the mental health
services (including the right to request a Mental Health Act assessment) should be a priority for the
Mental Health Trust.
9. In this Report, we have specified those occasions upon which we believe an opportunity to reengage
Chandran with the mental health services was lost. First, in 1997 following his discharge
from St. Martin’s Hospital when there was no adequate transfer of care from that hospital to his
GP because of the mix-up over his GP’s name. Secondly, despite Chandran’s attendance at the
Psychiatric Outpatients’ Clinic in July 1997, he was subsequently discharged because of his
non-attendance at two appointments in September 1997 and April 1998. In our view, instead of
being discharged from specialist psychiatric services, a thorough risk assessment of Chandran’s
mental health should have been conducted, which ought to have flagged up the past violent and
potentially violent incidents and ought to have identified the need for a plan to manage
his illness.
10. Thirdly, Chandran’s condition deteriorated from 1999 onwards such that, looking at the
Eligibility Criteria for a Service from the CMHT provided to us by the Trust, he appears to have
been eligible to receive help from the CMHT. Given the evidence of the family, he had by then
a history of violent behaviour due to mental health problems (although no criminal conviction
until 2001). As Dr Röhricht said, a history of that nature would have initiated a referral to the
CMHT had he been made aware of it when he saw Chandran on 25th May 2001. In our view,
had his family known whom they should contact when Chandran’s condition deteriorated and
been reassured that it was not in any way a betrayal of Chandran to seek help for him, it is likely
that his increasingly violent behaviour would have been flagged up and he would have been
eligible for help from the CMHT.
11. Fourthly, there was such an opportunity for psychiatric intervention when Chandran’s family
went to the police later in 2001. Dr Röhricht remarked to us that a family does not usually go to
the police on the first occasion of violence: there is normally a history of violent or threatening
behaviour. This was so in Chandran’s case and we agree with Dr Röhricht’s observation.
The Rôle and Response of the Metropolitan Police Service
12. As we have set out in this Report, Chandran’s sister and aunt were reluctant to report to the police
incidents when he had been violent or had threatened violence, and did not do so. The same
appears to have been true for Narayanan Sukumaran who does not seem to have informed the
police of Chandran’s violence towards him at any time until the letter was taken to East Ham
Police Station on 27th October 2001.
1 C.f. Standard four of the Mental Health National Service Framework, the aim of which is “to ensure that each person with severe mental illness receives the range of
mental health services they need; that crises are anticipated or prevented where possible; to ensure prompt and effective help if a crisis does occur; and timely access to an
appropriate and safe mental health place or hospital bed, including a secure bed, as close to home as possible.”
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