INQUIRY AFTER A HOMICIDE: THEMES, LESSONS

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INQUIRY AFTER A HOMICIDETHEMES, LESSONS
REFLECTIONS

• Dr Tim Exworthy
• Consultant Forensic Psychiatrist
• Oxleas NHS Foundation Trust
• tim.exworthy_at_oxleas.nhs.uk

15th Annual NAPICU Conference University of
York 9 September 2010
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PB Timeline

• Oct 1969 Born in London
• Mar 1993 Killed NS
• Sent to Rampton
• Jul 2001 Transferred to MSU
• Jan 2002 Moved to hostel
• 10.02.04 Informal admission to hospital
• 17.02.04 Killed BC, arrested.
• 15.04.04 Transferred to Broadmoor
• 25.04.04 Fatally assaulted RL
• 15.03.05 At CCC sentenced to life imprisonment

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Inquiry Timeline

• 17.02.04 Killed BC, arrested.
• 15.04.04 Transferred to Broadmoor
• 25.04.04 Fatally assaulted RL
• 15.03.05 At CCC sentenced to life imprisonment
• July 05 Inquiry established. Chair appointed
• Aug 05 Inquiry teams assemble
• Nov 05 Witness hearings begin
• Jun 08 Report submitted to NHS London
• Sep 09 Reports published

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PB INQUIRY Terms of reference

• To examine the relevant circumstances surrounding
  the treatment care of PB from discharge
  planning in Rampton to admission to Broadmoor
• To examine the appropriateness, quality
  adequacy of any assessment, including assessment
  of risk, care plan, treatment or supervision
• To examine adequacy of liaison, co-ordination,
  collaboration, communication organisational
  understanding between within the various
  agencies
• To prepare an independent report for NE London
  SHA, including key appropriate recommendations
  that will contribute to the continuous
  improvement development of local service models
  practice.

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Inquiry Process

• Legal basis
• HSG (94)27 Guidance on the discharge of
  mentally disordered people and their continuing
  care in the community.
• Article 2, ECHR the right to life
• Positive obligation of the State to protect the
  right to life,
• Procedural obligation for effective official
  investigation
• - independence
• - effectiveness
• - reasonable expedition
• - sufficient element of public scrutiny

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Inquiry Process

• Membership of Panel
• Independence - barrister
• - consultant forensic psychiatrist
• - senior nurse manager
• - former deputy director of social services
• Expert advice general psychiatrist
• Assisted by Verita to manage the inquiry
  process.
• (Transcribers)

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Inquiry Process

• Procedural
• Is not a trial (Criminal responsibility
  determined in criminal trial)
• Is not to make judgments on clinical competence
  in judicial sense
• Aims - to come to findings about care and
  treatment afforded to PB
• - to ensure better and safer practice in the
  future
• - to make general recommendations.
• Standard required
• Hindsight bias?

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Inquiry Process

• Practicalities

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Inquiry Process

• Practicalities
• Witness hearings 18 months from Nov 2005
• 64 witnesses, incl five for 2nd time.
• On 34 days
• Invited to the hearings
• Many prepared statements beforehand
• Most accompanied by solicitor
• Sent transcript for their comments
• Sent draft of report for comments
• Publication of reports

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Themes from the Inquiry

• Legal issues
• Communication
• Relapse and risk

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Legal Issues

• Status as a restricted patient
• care versus control
• reporting requirements of supervisors
• keeping HO informed
• MHRT
• medical representation
• reflecting teams opinion to tribunal
• Recall to hospital
• threshold
• mechanics
• recall or informal admission

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Communication

• Without proper communication and liaison there
  cannot be effective care either in hospital or in
  the community.
• Clunis Inquiry Report 1994 (p105)

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Communication

• At points of transition
• eg HSH to MSU
• forensic to general service
• out-patient to in-patient
• Within the team
• virtual community team
• liaison with hostel
• Beyond the team
• reports to Home Office/MoJ

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Relapse and Risk

• Terms of reference
• To examine the appropriateness, quality and
  adequacy of any assessment, including assessment
  of risk having regard to
• - his history of violence to others
• - his actual and assessed risk of potential
  harm to himself and others including the response
  by services to signs of relapse and deterioration
  in his mental health.
• Restriction Order (sec 41)
• . having regard to the nature of the offence,
  the antecedents of the offender and the risk of
  his committing further offences if set at large,
  that it is necessary for the protection of the
  public from serious harm

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Relapse and Risk

• Rampton
• 2 separate yet linked offence patterns I.O.
  street robberies
• Extensive use of instrumental violence to elicit
  money
• Triggered by increasing emotional difficulties
• environmental stresses
• drug abuse
• severe mental health difficulties.
• High risk of resuming criminal lifestyle
• Moderate risk of reoffending in similar way to
  I.O.
• Needs to develop full offence cycle and relapse
  prevention plan
• Needs to engage in drug and alcohol intervention

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Relapse and Risk

• Medium secure unit
• Psychology assessment considered
• Mental state underlying vulnerability to
  psychotic thought processes
• impaired capacity to deal with stresses
• Cognitive functioning immature behaviour
  likely to be residual effects of MI
• Personality style
• Criminogenic needs cognitive distortions to
  justify illegal activities
• Heterosexual relationships generic risk of
  violence not just Asian women

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Relapse and Risk

• Medium secure unit

• Final CPA relapse indicators
• - Developing paranoid ideas eg thinking people
  are following him spying on him
• becoming infatuated with females leading to
  inappropriate sexual behaviour
• - Abusing drugs, leading to risk of deterioration
  in his mental state.

Psychology relapse signature - Low mood -
Irritability - Subtle signs of increase in
paranoid ideas - Illogical statements
or disorganised reasoning -Escalating social
inappropriateness or sexually disinhibited
behaviour - Ideas regarding racism towards him or
expressed by him towards others
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Relapse and Risk

• Medium secure unit

Final CPA relapse indicators Developing
paranoid ideas eg thinking people are following
him spying on him Becoming infatuated with
females leading to inappropriate sexual
behaviour Abusing drugs, leading to risk of
deterioration in his mental state.
Sec 117 meeting Relapse indicators Paranoia
and suspiciousness Infatuation, especially with
Asian girls Drug and alcohol misuse Irregular
compliance with medication
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Relapse and Risk

• Handover CPA meeting Sept 2002
• Care plan listed early warning signs/relapse
  indicators as
• 1 paranoia and suspiciousness
• 2 drug use, especially cannabis
• 3 increased irritability and hostility towards
  people.
• Recent displays of such features dismissed as
  personality.
• MoJ Guidance for clinical supervisors
• Section 6 Provision of written information by
  the discharging hospital
• e) Any warning signs which might indicate a
  relapse of his mental state or a repetition of
  offending behaviour together with the time lapse
  in which this could occur, and details of any
  individuals or groups who may be at particular
  risk

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Relapse and Risk

• General psychiatrist on handover of risk
  information
• That was what was handed over from the forensic
  team, that the things to look out for were if he
  became infatuated with a young Asian woman and
  became very obviously psychotic.
• General points from the Inquiry
• 1 important risk information not included in
  risk assessments focus was restricted to
  relatively conspicuous relapse indicators
• 2 signs of relapse were identified, only to be
  dismissed as features of PBs personality
• 3 relatively little discussion about PB among
  his clinical team concerns raised by
  individuals left unresolved and then overtaken by
  events
• 4 psychiatric social supervisors inexperienced
  with complex forensic patients tendency to
  normalise his behaviour see it as distinct
  from relapse or risk of reoffending.

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Relapse and Risk

• Concluding thoughts
• 1 Past history present state future
  stressors
• systematic assessment of risk
• 2 Relapse risk are multifaceted
• 3 Assessment must lead to management of risk
• 4 EWS of relapse must lead to contingency plan
  when to intervene
• 5 Intervention requires boundary setting, leads
  to further assessment

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