During the night of 25
July 2000 D killed his grandmother. He later
pleaded guilty to manslaughter on the grounds of diminished
responsibility, and the court ordered that he be detained under what is
known as Treatment and Restriction Orders in a medium secure
hospital. D had been in receipt of mental health services from the
South London and Maudsley NHS Trust (SlaM) having been referred to
these services by his GP.

An independent mental health inquiry was formally set up in February
2003, by Lambeth Primary Care Trust, as required by National Health
Service Guidance, HSG (94) 27.


Early Years - 1977 -1990

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D's parents married in 1977. He was born in Carshalton, Surrey on 5
December 1977, an only child with a Russian mother and mixed
Jewish and Burmese parentage father. Father is known to have had a
history of bipolar affective disorder.
D's parents separated when he was six months old. Mother had
custody of D and moved to Brixton where she lived with D and her
mother.


Whilst living in Paris - 1997 – February 1999
D went to Paris to undertake a French studies course in 1997. In 1998
D converted to Islam, shaving his head, and growing a beard. He
became very strict in his adherence to his understanding of the
religion's requirements. It was at this time that he disengaged from his
course. Whilst in Paris it seems that D made at least two suicide
attempts.
March - May 1999
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On 4
March D's mother went to her GP, Dr C, to register concerns
about his behaviour since his return from France on vacation. He had
been very abusive to his mother and her female colleagues.

March - May 1999
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On 4
March D's mother went to her GP, Dr C, to register concerns
about his behaviour since his return from France on vacation. He had
been very abusive to his mother and her female colleagues.

She was concerned about his zealous frame of mind, he had become a
vegan, and was aggressively opposed to smoking and drinking. He
described himself to her as “the Antichrist”.
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On the morning of the 11
March his mother asked D to go to see the
GP, at the time he was cutting string from camping equipment –
seemingly in preparation for his intention to camp in central London.
As described by his mother “he looked terrible, his eyes were blank
and cold, he said 'Mummy, now we play” tied her hands together and
started to lead her upstairs in the house. Mother managed to push the
panic alarm as she passed it and at that “D snapped out of his
blankness and looked confused”. Mother ran from the house, freed her
hands and went straight to the GP who arranged a joint visit shortly
afterwards with the Rapid Assessment Team. The GP (Dr C) recorded
in his notes the possibility of “schizophrenia and mood disturbance,


This assessment led to D's eventual informal admission to Lloyd Still
Ward, St Thomas' Hospital after some difficulty in finding a bed for him.
Notes from the assessment suggest that he was flat, sometimes
inappropriate in his responses, and malleable. Included in the
immediate plan set out by the duty psychiatric SHO, was the potential
use of Section 5(2) of the Mental Health Act to prevent him leaving
hospital. It was reported by the family that they were not asked to
provide information relating to D and the family history.
No regular medication was prescribed during this time. The references
in his multidisciplinary working notes describe him at different times as
varying in his mood and presentation: being “perplexed and bizarre” in
his thoughts. Other entries suggest he was quiet and calm in his
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moods and behaviour. On the 19
March an entry states that he
“expresses ideas of reference”, “still thinks that accidents are
connected to him when he hears the sirens in the street. Mood is
changeable at times, appears elated”.

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D was formally discharged in his absence on Tuesday 30
March.
Remainder of 1999 and until July 2000
Throughout this time D had been living with his mother and was in daily
contact with his grandmother. However, D did not keep up with his
studies, he appears to have had some fleeting relationships and
indulged in some illicit drug usage.
During 2000 it seems that his relationship with his mother became
more strained, he appears to have become more self absorbed,
preoccupied and, as reported later by his mother, “to talk aggressively
to himself, he would slap his face and say 'stop it, stop it, stop it', then
tell me. 'it's not me talking, it's him talking'”. His self care deteriorated,
“his body would twitch, his face would grimace”. His mother did not
seek help or support for D or herself during this period.

July 2000
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On the 4
July D attempted to shoot himself in his bedroom with a
shotgun that belonged to his mother. He missed and damaged the
ceiling in his room. No professionals were informed of this incident at
the time or subsequently.

Because of her increasing concern about D, his mother visited Dr C on
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the morning of 17
July. Dr C spoke with Dr D that same day, initially
in regard to another patient, and faxed an urgent referral together with
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Dr G's initial referral letter of 7
July to the Rapid Assessment Team
(RAT) for D to be assessed.
Acting on this information, the RAT arranged to see D that same
afternoon. D attended the centre with his mother where they were
seen together by the RAT psychiatrist (Dr W) on duty that day and
Community Psychiatric Nurse K. During this assessment D was seen
with his mother present throughout.
The recorded Treatment Options discussed with D and his mother
were; the possibility of informal hospital admission which D declined;
“some form of talking therapy or counselling”; a future appointment with
the sector team at St Thomas' and prescription of an antidepressant,
Fluoxetine 20mg, brand name Prozac. The assessment outcome and
subsequent treatment proposed was based on a view that D was
depressed with suicidal ideation.

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On the 24
July D watched the film Gladiator at the cinema. It
emerged subsequently that D felt that this film spoke directly to him
and told him that “I needed to fight, materialise my demon in this world
by killing someone I loved”.
Early the following morning he went into his mother's room looking for
cigarettes. He went downstairs, but returned shortly after when he lay
on his mother's bed, then he started to stroke her and wanted to
massage her neck, at which time he put some pressure on her larynx.
His mother felt uneasy, got up, dressed and left the house taking the
dog to the park. Later she and D's grandmother returned to the house.
D's mother reports that D was hostile towards her during the rest of the
day; but he was warm and loving towards his grandmother.

As described by his mother “I knew that I couldn't stay, D was fidgeting
all the time, standing up, walking around, sitting down, shaking his
hands, slapping his face. I felt that D was going to hurt me, so I
decided to leave the house for the night and stay at my mother's flat”.
th th
Late at night on the 25
/early hours of 26 July D spread flammable
liquids around his grandmother's bed and outside her bedroom door.
He then set fire to these as she slept in the bed; she tried to get away
from the flames, but they struggled in the doorway and on the stairs
where D stabbed her repeatedly. A neighbour banged on the front
door alerted by the smoke coming from the bedroom upstairs. D
responded briefly, then ran from the house, later presenting himself to
Kennington police station.

The panel consider that the admission to hospital following the
assessment in March 1999 was the right course of action. The panel
acknowledge the pressure that Trust inpatient staff were facing in trying
to maintain a good quality service when under such pressure as a 140-
160% bed occupancy. This may well account for the fact that there is
little evidence of any purposeful activity to investigate or understand
this young man's mental health problems. This was reflected in the
manner of his discharge and can be illustrated by:- No evidence that the ward staff took account of the history of D's
maternal grandmother or father D's father apparently being rebuffed on a unduly narrow and
restricted understanding of confidentiality issues Staff not being mindful of the contribution that D's carers had to
make. D's father would have been able to provide information,
ensuring that a much fuller history of his mental state was
available No evidence that the Care Programme Approach (CPA) process
was initiated while D was on the ward, and it would appear that
this was a paper exercise after he failed to return from weekend
leave No evidence that, when the ward staff were informed by mother
that D had disappeared, attempts were made to establish where

he was or the risk that he might have presented to himself or
others The lack of detailed assessment work being completed during
this inpatient stay, the only option open on discharge was for D
to be placed on Level One CPA and a subsequent outpatient
appointment being offered The final diagnosis submitted to D's GP of 'unclear' was
unhelpful, unsatisfactory and gave no guidance to D's GP about
his future care and treatment

That D was placed on the CPA at Level One and followed up by the
outpatient appointment only, may reflect the reality of how inner city
services cope with the pressures on their services and how they
respond to people who present with early symptoms of psychosis. The
CPA categorisation is not questioned by the panel on the information
amassed by the clinical team at the time. However the absence of any
recorded preparation and planning prior to D's self discharge was
inadequate.

It is unreasonable to expect inpatient units to work under such a
sustained bombardment of pressure as experienced at that time. We
know this is a matter of resources and is not entirely controllable by
SLaM or PCT management, however this reinforces the need for
strong clinical leadership and management systems in order to make
clinical interventions and treatment purposeful.

Although the non urgent referral went astray, when it was eventually
brought to Dr D's attention on his return from leave by the GP, the right
action was taken promptly and D and his mother were seen the same
day. The assessment was multi disciplinary and the doctor and nurse
had read the referral letter from Dr G and the second referral fax from
Dr C before the assessment was undertaken.
This assessment did not appear to take full account of the known
history, the mental state assessment was not comprehensive and the
conclusion reached did not appear to correlate with the presenting
symptoms. The medication prescribed for a depressive condition in
line with the assessment was unlikely, in the panel's view, to have had
the desired effect.

No attempt was made to interview D on his own or his mother
separately. The panel was surprised to hear that it was standard
practice at that time not to interview service users and their carers
separately.
The panel has concerns regarding the quality of the assessment and
the subsequent outcome management plan in terms of medication
management and follow up. It is difficult to see that the
recommendation for “talking therapy”, for which there was a waiting
time following referral, of many months, was realistic in this
circumstance.
The panel has considered whether the offence was predictable or

We have considered whether the offence was preventable, and if it
would have happened if D's assessment and management plan had
been based on a diagnosis of a possible schizophrenic or psychotic
condition, rather than a depressive illness.

The assessment team were not in possession of the information about
D's attempt to shoot himself with a shotgun earlier in July. This is
information that might well have raised the awareness of all the
professionals involved to the level of risk that D posed to himself and
potentially to others. It is possible that such information would have
influenced both the assessment outcome and the management plan to
contain the level of risk.

Had an assessment of possible schizophrenia or psychosis been
made, it seems likely that the management plan might well have been
different, for example hospitalisation or intensive community follow-up,
or the use of anti psychotic medication.

We are not suggesting that the homicide was preventable. We are
however of the view that a different assessment and management plan
might have reduced the risk of violent behaviour by D to himself or
others.

Clinical and managerial supervision for non-medical staff in both the
A&T and Case Management and Outreach Team were provided on a
regular basis by various members of the teams they worked in.
Supervision for doctors was provided by the sector senior clinician. It
appears that agency nurses were not included as part of the appraisal
system even though some staff were long term and worked within the
team permanently.

The panel was concerned that record keeping in the RAT and the
follow through of management plans seemed ad hoc. The need for
formal record keeping and the processes of collating previous records
and information is fundamental to the function of all teams, particularly
to a disparate team such as RAT was at that time. The Friday review of
the week's work meeting does not appear to have had a clear remit to
further review, consider and agree treatment options and follow
through plans.
This was compounded by the absence of any designated management
function in the team and a degree of ambivalence on the role of the
consultant psychiatrist in supervision of clinicians rostered onto the
team.

Supervision arrangements for doctors in the RAT were incomplete
because those with responsibility for clinical supervision were external
to that team and therefore not fully apprised of their work and clients
being considered. This meant that individuals' medical practice was
insufficiently overseen and this aspect of their work not clearly


At the time of the assessment of D, neither the doctor nor nurse saw D
or his mother separately nor was it recognised as the normal process.
The panel considered this poor practice as was also the lack of a
documented report of the assessment undertaken.

The panel could not determine that the Friday work review meeting
was documented and recorded regarding decisions relating to service
users, or how these were arrived at. Our view is that this was an
inadequate arrangement that created an unstructured review process.

The panel was aware that the Internal Inquiry report stated that there
was a delay in the Trust being informed of the incident. It is
understood that this has been rectified.