INQUIRY AFTER A HOMICIDE: THEMES, LESSONS & REFLECTIONS

1. INQUIRY AFTER A HOMICIDE:THEMES, LESSONS & REFLECTIONS Dr Tim Exworthy Consultant Forensic Psychiatrist Oxleas NHS Foundation Trust tim.exworthy@oxleas.nhs.uk 15th Annual NAPICU Conference University of York 9 September 2010

4. 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

5. 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

6. 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.

8. 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

9. 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)

10. 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?

11. Inquiry Process • Practicalities

12. 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

13. Themes from the Inquiry • Legal issues • Communication • Relapse and risk

14. Legal Issues • Status as a restricted patient ‘care versus control’ reporting requirements of supervisors keeping HO informed • MHRT medical representation reflecting team’s opinion to tribunal • Recall to hospital threshold mechanics recall or informal admission

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

16. 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

17. 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 …”

18. 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

19. 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

20. 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

21. Relapse and Risk 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 Medium secure unit

22. 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;

23. 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 PB’s 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.

24. 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