INQUIRY AFTER A HOMICIDE:INQUIRY AFTER A HOMICIDE:THEMES, LESSONS & THEMES, LESSONS &

REFLECTIONSREFLECTIONS

Dr Tim ExworthyDr Tim Exworthy

Consultant Forensic PsychiatristConsultant Forensic Psychiatrist

Oxleas NHS Foundation TrustOxleas NHS Foundation Trusttim.exworthy@oxleas.nhs.uk

15th Annual NAPICU Conference

University of York

9 September 2010

PB: TimelinePB: TimelineOct 1969Oct 1969 Born in LondonBorn in London

Mar 1993Mar 1993 Killed NSKilled NS

Sent to RamptonSent to Rampton

Jul 2001Jul 2001 Transferred to MSUTransferred to MSU

Jan 2002Jan 2002 Moved to hostelMoved to hostel

10.02.0410.02.04 Informal admission to hospitalInformal admission to hospital

17.02.0417.02.04 Killed BC, arrested.Killed BC, arrested.

15.04.0415.04.04 Transferred to BroadmoorTransferred to Broadmoor

25.04.0425.04.04 Fatally assaulted RLFatally assaulted RL

15.03.0515.03.05 At CCC sentenced to life At CCC sentenced to life imprisonmentimprisonment

Inquiry : TimelineInquiry : Timeline

17.02.0417.02.04 Killed BC, arrested.Killed BC, arrested.15.04.0415.04.04 Transferred to BroadmoorTransferred to Broadmoor25.04.0425.04.04 Fatally assaulted RLFatally assaulted RL15.03.0515.03.05 At CCC sentenced to life At CCC sentenced to life

imprisonmentimprisonment

July 05July 05 Inquiry established. Chair appointedInquiry established. Chair appointedAug 05Aug 05 Inquiry teams assembleInquiry teams assembleNov 05Nov 05 Witness hearings beginWitness hearings beginJun 08Jun 08 Report submitted to NHS LondonReport submitted to NHS LondonSep 09Sep 09 Reports publishedReports published

PB INQUIRY: Terms of referencePB INQUIRY: Terms of reference

To examine the relevant circumstances surrounding the treatment To examine the relevant circumstances surrounding the treatment & care of PB … from discharge planning in Rampton to admission & care of PB … from discharge planning in Rampton to admission to Broadmoor;to Broadmoor;

To examine the appropriateness, quality & adequacy of any To examine the appropriateness, quality & adequacy of any assessment, including assessment of risk, care plan, treatment or assessment, including assessment of risk, care plan, treatment or supervision;supervision;

To examine adequacy of liaison, co-ordination, collaboration, To examine adequacy of liaison, co-ordination, collaboration, communication & organisational understanding between & within communication & organisational understanding between & within the various agencies;the various agencies;

To prepare an independent report for NE London SHA, including To prepare an independent report for NE London SHA, including key & appropriate recommendations that will contribute to the key & appropriate recommendations that will contribute to the continuous improvement & development of local service models & continuous improvement & development of local service models & practice.practice.

Inquiry ProcessInquiry Process

Legal basisLegal basisHSG (94)27: HSG (94)27: Guidance on the discharge of mentally Guidance on the discharge of mentally disordered people and their continuing care in the disordered people and their continuing care in the

community.community.

Article 2, ECHR: the right to lifeArticle 2, ECHR: the right to lifePositive obligation of the State to protect the right to life,Positive obligation of the State to protect the right to life,Procedural obligation for effective official investigation –Procedural obligation for effective official investigation –

- independence- independence- effectiveness- effectiveness- reasonable expedition- reasonable expedition- sufficient element of public scrutiny- sufficient element of public scrutiny

Inquiry ProcessInquiry Process

Membership of PanelMembership of PanelIndependenceIndependence - barrister- barrister

- consultant forensic psychiatrist- consultant forensic psychiatrist

- senior nurse manager- senior nurse manager

- former deputy director of social services- former deputy director of social services

Expert advice – general psychiatristExpert advice – general psychiatrist

Assisted by Verita to manage the inquiry process.Assisted by Verita to manage the inquiry process.

(Transcribers) (Transcribers)

Inquiry ProcessInquiry Process

ProceduralProceduralIs not a trialIs not a trial (Criminal responsibility determined in criminal trial)(Criminal responsibility determined in criminal trial)Is not to make judgments on clinical competence in judicial senseIs not to make judgments on clinical competence in judicial sense

Aims:Aims: - to come to findings about care and treatment afforded to - to come to findings about care and treatment afforded to PBPB

- to ensure better and safer practice in the future- to ensure better and safer practice in the future- to make general recommendations.- to make general recommendations.

Standard requiredStandard required

Hindsight bias?Hindsight bias?

Inquiry ProcessInquiry Process

PracticalitiesPracticalities

Inquiry ProcessInquiry Process PracticalitiesPracticalities

Witness hearings :Witness hearings : 18 months from Nov 200518 months from Nov 200564 witnesses, incl five for 264 witnesses, incl five for 2ndnd time. time.On 34 daysOn 34 days

Invited to the hearingsInvited to the hearingsMany prepared statements Many prepared statements

beforehandbeforehandMost accompanied by solicitorMost accompanied by solicitorSent transcript for their commentsSent transcript for their commentsSent draft of report for commentsSent draft of report for comments

Publication of reportsPublication of reports

Themes from the InquiryThemes from the Inquiry

Legal issues Legal issues

Communication Communication

Relapse and riskRelapse and risk

Legal IssuesLegal Issues1.1. Status as a restricted patientStatus as a restricted patient

‘‘care versus control’care versus control’ reporting requirements of supervisorsreporting requirements of supervisorskeeping HO informedkeeping HO informed

• MHRTMHRTmedical representationmedical representationreflecting team’s opinion to tribunalreflecting team’s opinion to tribunal

3.3. Recall to hospitalRecall to hospitalthresholdthresholdmechanicsmechanicsrecall or informal admissionrecall or informal admission

CommunicationCommunication

““Without proper communication and liaison there Without proper communication and liaison there cannot be effective care either in hospital or in cannot be effective care either in hospital or in

the community”.the community”.

Clunis Inquiry Report 1994 (p105)Clunis Inquiry Report 1994 (p105)

CommunicationCommunication

1.1. At points of transitionAt points of transitioneg eg HSH to MSUHSH to MSU

forensic to general serviceforensic to general serviceout-patient to in-patientout-patient to in-patient

2.2. Within the teamWithin the teamvirtual community teamvirtual community teamliaison with hostelliaison with hostel

3.3. Beyond the teamBeyond the teamreports to Home Office/MoJreports to Home Office/MoJ

Relapse and RiskRelapse and RiskTerms of referenceTerms of reference::To examine the appropriateness, quality and adequacy of To examine the appropriateness, quality and adequacy of

any assessment, including assessment of risk … having any assessment, including assessment of risk … having regard to:regard to:

- his history of violence to others- his history of violence to others- his actual and assessed risk of potential harm to - his actual and assessed risk of potential harm to

himself and others including the response by services to himself and others including the response by services to signs of relapse and deterioration in his mental health.signs of relapse and deterioration in his mental health.

Restriction OrderRestriction Order (sec 41) (sec 41) “… “…. . having regard to the nature of the offence, the having regard to the nature of the offence, the

antecedents of the offender and the risk of his antecedents of the offender and the risk of his committing further offences if set at large, that it is committing further offences if set at large, that it is necessary for the protection of the public from serious necessary for the protection of the public from serious harmharm …” …”

Relapse and RiskRelapse and RiskRamptonRampton 2 separate yet linked offence patterns – I.O. & street 2 separate yet linked offence patterns – I.O. & street

robberiesrobberies Extensive use of instrumental violence to elicit moneyExtensive use of instrumental violence to elicit money

Triggered by Triggered by increasing emotional difficultiesincreasing emotional difficultiesenvironmental stressesenvironmental stressesdrug abusedrug abusesevere mental health difficulties.severe mental health difficulties.

High risk of resuming criminal lifestyleHigh risk of resuming criminal lifestyle Moderate risk of reoffending in similar way to I.O.Moderate risk of reoffending in similar way to I.O.

Needs to develop full offence cycle and relapse prevention Needs to develop full offence cycle and relapse prevention planplan

Needs to engage in drug and alcohol interventionNeeds to engage in drug and alcohol intervention

Relapse and RiskRelapse and RiskMedium secure unitMedium secure unit

Psychology assessment considered:Psychology assessment considered:

Mental state – underlying vulnerability to psychotic thought Mental state – underlying vulnerability to psychotic thought processesprocessesimpaired capacity to deal with stressesimpaired capacity to deal with stresses

Cognitive functioning – ‘immature’ behaviour likely to be residual Cognitive functioning – ‘immature’ behaviour likely to be residual effects of MIeffects of MI

Personality stylePersonality styleCriminogenic needs – cognitive distortions to justify illegal Criminogenic needs – cognitive distortions to justify illegal

activitiesactivitiesHeterosexual relationships – generic risk of violence & not just Heterosexual relationships – generic risk of violence & not just

Asian womenAsian women

Relapse and RiskRelapse and RiskMedium secure unitMedium secure unit

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

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.

Relapse and RiskRelapse and RiskMedium secure unitMedium 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

Relapse and RiskRelapse and RiskHandover CPA meetingHandover CPA meeting – Sept 2002 – Sept 2002

Care plan listed early warning signs/relapse indicators as:Care plan listed early warning signs/relapse indicators as:

1] paranoia and suspiciousness1] paranoia and suspiciousness2] drug use, especially cannabis2] drug use, especially cannabis3] increased irritability and hostility towards people.3] increased irritability and hostility towards people.

Recent displays of such features dismissed as ‘personality’.Recent displays of such features dismissed as ‘personality’.

MoJ: Guidance for clinical supervisorsMoJ: Guidance for clinical supervisors

Section 6 – Provision of written information by the discharging hospitalSection 6 – Provision of written information by the discharging hospital e) Any warning signs which might indicate a relapse of his mental state or a 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 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 could occur, and details of any individuals or groups who may be at particular risk;particular risk;

Relapse and RiskRelapse and RiskGeneral psychiatrist: on handover of risk informationGeneral psychiatrist: on handover of risk information““That was what was handed over from the forensic team, that the 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 things to look out for were if he became infatuated with a young Asian woman and became very obviously psychotic.”Asian woman and became very obviously psychotic.”

General points from the InquiryGeneral points from the Inquiry::

1] important risk information not included in risk assessments & focus 1] important risk information not included in risk assessments & focus was restricted to relatively conspicuous relapse indicators;was restricted to relatively conspicuous relapse indicators;

2] signs of relapse were identified, only to be dismissed as features of 2] signs of relapse were identified, only to be dismissed as features of PB’s personality;PB’s personality;

3] relatively little discussion about PB among his clinical team – 3] relatively little discussion about PB among his clinical team – concerns raised by individuals left unresolved and then overtaken concerns raised by individuals left unresolved and then overtaken by events;by events;

4] psychiatric & social supervisors inexperienced with complex forensic 4] psychiatric & social supervisors inexperienced with complex forensic patients; tendency to ‘normalise’ his behaviour & see it as distinct patients; tendency to ‘normalise’ his behaviour & see it as distinct from relapse or risk of reoffending.from relapse or risk of reoffending.

Relapse and RiskRelapse and RiskConcluding thoughtsConcluding thoughts

1] Past history + present state + future stressors1] Past history + present state + future stressors

= systematic assessment of risk= systematic assessment of risk

2] Relapse & risk are multifaceted2] Relapse & risk are multifaceted

3] Assessment must lead to management of risk;3] Assessment must lead to management of risk;

4] EWS of relapse must lead to contingency plan – 4] EWS of relapse must lead to contingency plan – when to intervenewhen to intervene

5] Intervention requires boundary setting, leads to 5] Intervention requires boundary setting, leads to further assessmentfurther assessment