I had a meeting with the Procurator Fiscals office yesterday, to start to draw the final things together for Tony.
Apart from give me a copy of Tony’s note the whole meeting left me with a negative feeling that the system doesn’t work and it knows it doesn’t work and it is fine with that.
I have some concerns about Tony’s case, not to find cause and apportion blame, there is no-one to blame, but to look at the system of support and see where the gaps are. Cause Tony fell through some gaps.
I was trying to speak to the Fiscal in a lessons learned way, however he kept bringing back to not being able to bring a direct link back to Tony’s case. Which I did not want to do.
I do think Tony was a vulnerable person, some who was diagnosed as Bi-Polar is a vulnerable person and I think that is where the system failed. When he moved house in October 2005 he updated his address with his doctor and then received a letter telling him that he was out of the catchment area and therefore would be de-registered and his records sent back to the central records.
To me this looks like a pure admin task, I assume that it was done without looking at the contents of his records. However, for someone who was depressed, mildly paranoid and lacked motivation (all typical of Bi-Polar suffers) the nature of the letter looked like another rejection from the world and confirmed Tony’s belief that he was not making any impact on this world. That people could brush him off, out of hand.
My fear is that this happens daily, not necessarily with mental welfare patients, but with anyone who is potentially vulnerable. This system doesn’t take into account the ability of these people, whether they are able to register with a new doctor.
From speaking to my doctor, who was Tony’s doctor, I know there was a “scrabble” by the welfare services when Tony was found. He apparently caught them unawares…… social services were not ready for him……
Maybe that furthers my belief that the system doesnâ€™t work. I do not want to make this a belief a crusade, or let it consume my life, I would just like to try and make sure other people are not falling through gaps in the system and where there is the potential for a positive outcome our support systems are the best they can be.