Extracts
Simon Rawcliffe was born in June 1972. He was an only child. His parents separated when he was around 3 years old. His father continued to see him for a period, but contact was then lost until Simon Rawcliffe was fourteen. There was occasional contact after this, but his father, who was a lorry driver, was often away. He later remarried.
Simon Rawcliffe’s birth and early development was normal. There were no significant events in his
childhood. He was a healthy child, but was investigated by a paediatrician after a febrile convulsion
at the age of 7. Nothing of significance was uncovered apart from an underlying infection. There were
some problems at school and he was excluded on one occasion. He left school with GCSE
qualifications to join a catering course at a local college.
He moved out of the family home and found
employment until 1991, as a chef in a local pub restaurant.
At the age of eighteen Simon initiated contact with his father and they used to spend time in each other’s company on a regular basis. They would go fishing and shooting together. His father died unexpectedly of a heart attack at the age of forty-seven.
Up to this stage in his life there is no history from the documents that we read to suggest any significant behavioural (conduct) disorder as a child, or significant personality difficulties in his teenage years. The only suggestion of difficult behaviour came from a single detailed report that mentioned the school expulsion.
Simon Rawcliffe’s mother believes that the death of Simon’s father was the catalyst for the mental health, and other problems, suffered by her son. Also at around the same time a close friend of his died in an accident.
Following the death of his father he began to abuse drugs, and he lost his job. He committed property offences to fund his drug habit. He also presented with aggressive behaviour for the first time, to our knowledge.
Liaquat Ali [ the victim ]was born on 28 November 1968. He had been living apart from his wife and child for some time, and prior to his death he was living in a bed-sit at 8/10 Wash Lane, Bury. This accommodation comprised of two houses knocked together to form bed sitting rooms that were let to persons in receipt of housing benefit.
Sometime in the early hours of the 16 September 1999 he met his death.
The exact order of events
remains unclear. At about 0340 hours he was heard moaning outside the property by another resident.
She went to help and found him lying outside on the path. She brought him in and left him lying on
a sofa in the sitting room.
She checked on him just over an hour later, and he appeared comfortable.
Another resident got up at around 0840 hrs and went downstairs to find Liaquat Ali lying on the
settee. There was blood and broken glass on his face and shirt.
There was broken glass and pieces of
broken wood on the carpet near to the settee. An ambulance was called, but he was found to be dead.
This was a tragic loss of life.
His eldest sister described him as a quiet man who would not harm anyone. However he had an alcohol problem, had lost stability in his life, and because of this he could place himself in difficult situations.
Simon Rawcliffe was convicted of his murder.
There is certainly no evidence that in this case one could have predicted a homicide. Nevertheless, his risks at the time were not adequately assessed. His mental illness was poorly understood, and there was not an agreed clinical formulation for all staff to work with.
It is for this reason that we agreed to the request made by the Strategic Health Authority to remove from this report the names of all of those professionals involved in the care of Simon Rawcliffe.
{ As a result there ia multiplicity of Consultant ....1,2,3,4,5,6,7,8 and similarly nurse ...1,2,3 ..... and social worker ....1,2,3, ..... it's difficult to see the wood for all the trees - but inevitable. ] When unwell, he presented as grandiose, deluded,
elated, overactive, disinhibited, and aggressive.
He was difficult to keep on the ward, and when absent without leave, drank alcohol and
probably used drugs. He had no insight into his illness, was non compliant with medication, and between
admissions was lost to mental health services. However he was at times still intimidating and he was thought to be using drugs. However, management input was under resourced, the training status for
psychiatrists had been lost, and the involvement of consultants and the trust grade doctors on the
wards and in the community care was poor because of staffing deficits.
Those interviewed from the Acute Trust in Bury (at Board level) disagreed with this analysis.
The inpatient service was described as 'nurse led'. The community nursing staff were overloaded by
excessive caseloads. We also received evidence that this problem was further
compounded by the poor relationship between the Bury Health Care Trust and Bury and Rochdale
Health Authority, with little trust on either side. In 2001/2002 the expenditure per head of the population (for
adult services) on mental health was £62 for England, in North West Region £52, and at the bottom
of the league Bury and Rochdale with £36. All of these figures confirm that Bury (and Rochdale) was
at the bottom of the resource league, and had been for some time
How did this sorry state of affairs develop? We have seen an exchange of letters over 2000/2001
between Chief Executive 1 and Chief Executive 3, the Chief Executive of the Health Authority,
which indicates that the funding problems were recognised. However, until the 2001 meeting with
Manager 2 and Chief Executive 2 the Health Authority was of the view that money given to the
Trust for mental health would be spent elsewhere, on other services. There was some evidence of
this from the information that we were given. The Local Implementation Planning (LIP) process
began in 2000. The total spending on mental health services by the Trust was £2,719,000 and the
Trust received £4,000,000. Not all of this difference can be attributed to corporate overhead costs.
To place these figures in context, this was for the year after the death of Liaquat Ali. If the situation
was similar pre-2000, then this would explain why, over time, an unsafe service developed.
It was to this service that Simon Rawcliffe was admitted to in 1999. On the 11 April 1999, he returned to the ward after a brief period of leave and was noted to have drunk
alcohol. Later, he assaulted another patient, and staff felt so intimidated that the police were called. Suitable aftercare observation, suitable accommodation, suitable regularity in care and treatment was never obtained. The last community psychiatric nurse (CPN) Community Nurse 1 to see him described 8/10 Wash
Lane as the worst environment he had ever visited in order to see a discharged patient.
Following his arrest, his mental state deteriorated during his remand to prison and he required
transfer to Ashworth High Security Hospital. He improved enough for his trial to go ahead. He
pleaded not guilty, but was convicted of murder and he received a life sentence. His legal team did not
propose a psychiatric defence.
ED:-
When ill he was racially abusive, and racially threatening. His final living place was in poor conditions. He bullied an asian man there, and assaulted him, eventually killed him, although continuing to deny it. In the longterm secure placement , after his trial, taking the powerful atypical clozapine he is said to have made a very good improvement.
He was too ill for us to see him, and was unable to give
consent for the Inquiry Panel to see his medical and social services records.
Legal advice from Bury Primary Care Trust was obtained. The advice was that it was reasonable to
obtain these records on public interest grounds. This was what we did.
In 1993, he was admitted to Fairfield Hospital, Bury after a conviction for theft and burglary.
A
diagnosis of schizophrenia was made, but he did not co-operate with discharge arrangements. There
were further admissions after this, and he was at various times an inpatient at Fairfield Hospital, the
psychiatric inpatient unit at Bolton General Hospital, and Winwick Hospital, Warrington.
His admissions all followed contact with the police.
In hospital, he was at times threatening and he could be violent.
Witness statements from local people at the time of the trial described Simon at around this time asa bit of a nutter”. He was loud and inappropriate at times in the community. He was known formaking threatening and racist remarks:-
he hated Asian lads who attended the Asian College……… he would shout ‘ you fuckin black
bastards fuck off from our country……….”
Another witness in August 1998 described him as walking the streets with a baseball bat and heard
him say:
I’m going to kill another Paki soon, I hate them.”
He was known to the police as a local nuisance, but not a man with a potential for serious violence.
When discharged to the community he avoided follow up, there was little
stability of accommodation, and he used illicit drugs, which complicated his mental health
assessments.
This was his second admission to a secure psychiatric unit. At the time, he had an address in Bolton, but was arrested in Bury after walking through the streets with what appeared to be a gun. He aimed it at people, made threats to kill, and was aggressive and abusive. He had been drinking alcohol and smoking cannabis.
On the 16 February 1996, a charge nurse catalogued no fewer than fifteen incidents over a 3-week
period, where he had made threats of violence, or had been involved in acts of violence to staff or
other patients.
Soon after this he was transferred to the high dependency (secure) unit at Winwick
Hospital. He appeared to be hypomanic. Problems with his behaviour continued and he exposed
himself to a female patient. He said that Hitler was making peace with him.
He was placed on special observations, and began to improve and returned to Bolton Hospital on 5
March 1996.
At a Section 117 meeting on 19 March 1996, Consultant 8 said to Simon Rawcliffe that he was not
mentally ill but personality disordered with drug-induced psychosis.
In prison, he presented with clear symptoms of schizophrenia.
Bury mental health services, at that time were described to us by some of those working in the service
as under funded, and unsupported by Bury Health Care NHS Trust.
Morale amongst frontline staff was
described as high.
Relationships between frontline nursing and social work staff were good, but
made difficult by working out of different bases.
According to the information available to the Panel, Bury was probably one of the most poorly funded
mental health services in the country.
There were fears that money given to the Trust for mental health would not be spent in this service.
The management structures in place for the mental
health service were inadequately resourced and there was no strategic vision.
He remained a difficult
management problem on the ward, but because the missing notes were never recovered [ Ed:- it is said that Rawlings burnt them ] and no attempt was made to collect a new set of past psychiatric reports and summaries, the experience of the Scott Clinic[ Ed:- aneighbouring secure placement where he stayed for thirteen months ... the transfer back was not satisfactory, lacking definition, lacking receptive preparation
"During Simon Rawcliffe’s admission to the Scott Clinic, he and his mother received positive and
well-documented social care support from social work service based at this secure unit. The
forward care plan for his after care was well coordinated. However, the organisation of local
services following discharge was poor, and there were unacceptable delays."
} , acquired over a thirteen month period was not utilized. This resulted in misjudgementsabout the extent of his recovery and the likelihood of him cooperating with aftercare.
He was discharged on the 27 February 1998 by which time his general practitioner had been
identified. On the same date a detailed discharge letter was sent to Consultant 1. Simon Rawcliffe’s
next depot injection was due on the 3 March 1998. This letter was not sent on to the CPN notes until
21 May 1998.
His mother described him as ‘almost back to his normal self’ by the time of discharge. It is
unfortunate that the after care plan was so poorly coordinated after this discharge, by services at
Bury.
Nursing reports describe the difficulties he caused to staff, and he was eventually detained.
He was arrested (there were no subsequent charges), but was returned to the ward at midnight. He
said that he would get a gun and shoot three named nurses.
Risk was assessed as high, medication was
given and special observations were implemented. There was no serious incident review.
....."
Rawlins was never given a firm and clear psychiatric diagnosis. The different diagnoses left nursing staff to see his misbehaviour as that of a personality disorder – asserted by one consultant, or as reactions to street acquired drugs. Nursing clarity is not helped by the prescription of medications which deal with different mental illness.
In the firmly secure conditions of prison and the penultimate long admission in a secure Unit – the behaviour observed in one that was outside the catchment area pointed definitely to his behaviour being from a continuing serious mental illness, behaviour that was considerably improved when he received long term medication, and which relapsed into florid illness, when he was out of authoritative supervision, defied medication, and took drugs.