Jane Mishcon was appointed as Chair of the Inquiry.
She is a barrister at Hailsham Chambers whose main area of practice is clinical negligence.
She has chaired nine inquiries following homicides committed by psychiatric patients.
The other Panel members appointed were:
Dr Tim Exworthy, a consultant forensic psychiatrist at Oxleas NHS Foundation Trust.
Stuart Wix is a forensic nurse consultant at Birmingham and Solihull Mental Health Foundation Trust.
Mike Lindsey is a former deputy director of social services at Shropshire County Council.
Professor Tom Sensky, a Professor of Psychological Medicine and a consultant psychiatrist, provided expert advice to the Pane
Bryant was a known schizophrenia case although not taken into the mental health services until after his manslaughter of the daughter of his employer in 1994
Two brothers were affected similarly: one attacked his mother with a knife.
Bryant was seven years in Rampton, during the last four seemingly benefiting from medication - a minor dosage of stelazine - so that he was judged to be likely to have himself released from the Secure Hospital in some way on to care in the community.His earlier stay had not gone so well. He was considered overfamiliar and intrusively self confidnet.
A Tribunal decision towards that effect was adjourned until appropriate subsequent care situations and supervision arrangments were in place. Unusually these were obtained within six months of his intermediate placement in a Medium Secure Unit, and his transfer to a supported Hostel then went forward. The average stay in a Medium Secure Unit after a Homicide, and after some years in a Secure Hospital, might be two to three years preparation in that Unit.
In hindsight the Inquiry Panel is surprisd at the way the move forward was allowed, and suggests if a Consultant in charge had attended the Tribunal hearing himself, instead of a realitively inexperienced Specialist registrar whom he was supervising, the Tribunal would have been able to be persuaded that a longer intermediate observation and more gradual preparation was a better option, which the Tribunal would have accepted.
The move to a hostel went ahead.
The key worker was not what was anticipated.
A new Social worker introduced themselves. And new staff to observe and bear in mind his previous relapses.
The Hostel was in an area where drug misuse and distribution was a likelihood, and street sex work available.
Bryant was two years at the Hostel, seemingly compliant with the core impositions, but inclined to fray at the margins, finding things to complain about that always had a small basisof reasonablity. He continued his stance of taking a lead over the other residents. He continually challenged and made uncomfortable the pace and range of the restrictions on him, but always sufficiently gave in, for there to appear to be no clear evidence of illness resuming as an influence for that. He took the offensive in trying to get his own way, not really ever giving up on his ability to get what he wanted.
There was a fracas in the house of young woman where she accused him of being sexually offensive and peristent for which he was awaiting police interrogation.
Some youths were ween opposite the hostel as though going to retaliate against Bryant.
On this account he was moved as an informal patient to a mental health Ward, some distance away in London
The Inquiry panal notes ' He was back in hospital in a psychiatric ward, serious allegations had been made against him which were going to be investigated by the police, he was under threat of recall as a compulsorily detained patient and he did not know where he was going to go from Topaz Ward if he were not recalled.' The Hostel did not want him back
47. Sometime that afternoon, probably just before 15.00, Peter Bryan telephoned the Manager of Riverside House and told her that staff on the ward were saying that there was a shortage of beds and that he would have to come back to Riverside House. 48. The Manager explained to Peter Bryan that he would not be able to return to Riverside House and that they would take care of his belongings.
A manager at the hostel concluded that the continual complaints pointed to there being appropriate apprehension of an illness element emerging.
Formal assessment could not disclose enough to call active schizophrenia.
Unfortunately though this was the case.
Bryant slaughtered and dis-membered a vulnerable and exploited available man, subsequently killing a fellow inmate shortly after being moved to Broadmoor.
Peter Bryan had apparently met Brian Cherry through a young girl, P8, whom he had befriended some two years previously.
They had met through her friend P7 who was a friend of one of the residents in Riverside House.
According to her witness statement to the police, P8 was a habitual user of drugs, mainly crack cocaine. She had known Brian Cherry for over a year and it was clear that he was infatuated with her.
He believed that she was his girlfriend although there was never any sexual relationship between them.
She admitted that she took advantage of this fact and his loneliness to extract money from him to pay for her drug habit.
She would visit him with her friend P7 about four times a week at any time of the day and he would allow them to drink and take drugs in his flat.
She said that Brian Cherry would give her more than £100 a week. She would tell him that it was for minicabs because she was banned from driving.
She understood that the money came from compensation that he had received
for an injury which he had suffered and his disability benefit. She believed that he had given her something between £4,000 and £5,000 in total over the period that she had known him.
He never asked for anything in return.
Bryant had a long story of social misbehaviour before his illness declared itself, bullying a continuing part of it.
A percipient psychologist had written a long summary of the benefit of twelve or so interviews over three months, in one of which there is reminder that social misfit behaviour might be put down to the 'personality' persistence of the earlier years, when in fact it would be an early expression of the illness returning.
[ An earlier psychiatrist in years gone by put it this way " a little bit of schizophrenia is schizophrenia" ]
Or, put another way anything raising doubts about current behaviour in someone who has shown schizophrenia previously is to be taken as schizophrenia for the time being as a guide to working practice
WE are not told about any blood testing for medication levels.
A worry about gynaecomastia is never elucidated nor accounted for.
It is not stated that it was noticed in Rampton.
The stelazine has been discontiued, and olanzapine put in place - a very small dosage 5mgms; a little time before community tragedy, increased to 10 mgms. He had put on two stones in weight. That and observation suggests it was being taken
All important arrangements for the support of a patient in the community - such as (in PBs case) drug counselling and rehabilitative activities - should be put in place prior to the patient?s discharge from a medium secure unit. If this is not possible, the risks must be explicitly considered within the discharge plan.
Where possible the patient's RMO should personally attend the MHRT of any restricted patient, but in particular any MHRT at which a section 37/41 patient?s discharge from hospital into the community is likely to be the outcome.
The following areas need to be considered with regard to risk assessment of forensic patients: There is a need for a single evidence-based risk assessment format, with associated training and multidisciplinary input Risk assessments should be completed by members of at least two professions within the team and shared with the remainder in draft form before completion There should be a formulation of the individual?s risk which should be tied in with the known historical risks with a clear indication as to what, if anything, has changed The risk assessment should form an integral part of the CPA process and documentation The risk assessment document should be regularly reviewed and updated and the patient and any carers should be involved in the process of its formation and review The risk assessment document should be easily accessed.
The Police Services should review the way that their local MAPPAs respond to allegations of a serious nature made in respect of an individual who is believed to be a restricted patient. Where such a patient has previous convictions for violence, the allegation should be investigated as a matter of urgency.
The two professionals (RMO5 and Social Worker 5) who provided statutory supervision for this unusual and complicated Section 37/41 patient were a general adult psychiatrist who never before had had responsibility for a patient who had killed someone, and a very inexperienced social worker who had no training in mental health. It may be that in the grand scheme of things, Peter Bryant was let down to some degree by these professionals, but the Panel are of the view that they should never have been asked to take responsibility for someone like Peter Bryant in the first place.
The members of the community team also failed to work together as a proper team, and instead tended to work as individuals who each happened to have been allocated to Peter Bryant's care.
This made it much easier for Peter Bryant to manipulate situations by convincing the individual professionals that he had plausible explanations for any concerns they might have had about his mental state.
This allowed him to deflect and diminish such concerns.
Even when they met as a team for a CPA or an emergency meeting, Peter Bryant managed to hijack the meetings to deal with his written Agendas, and the professionals
became repeatedly embroiled with him in negotiation over his many and repetitive demands and complaints,
and were thereby distracted from focusing their efforts on assessing his mental health.
Comment
The problem here is how to conclude that there is some schizophrenia returning, influencing and there to direct behaviour, how to draw the line somewhere, and what to do about the uncertainties.
Uncertainty and frustration coming together with the absence of a routine are breakdown warnings for schizophrenia.
Changes of personnel and base prevent continuous monitoring.
What was known was that Bryant 'pushed' until boundaries were accepted, when he moved off and tried again elsewhere. That behaviour was manageable in a tight base with sustained observation and the same personnel. Outside , and in particular the outside that he got involved with, was not one that was always going to cope with him.
It is not clear that the Hostel, could find out and receive back an assessment of what he was up to outside. They were uncertain themsleves about him, which would be noted by him.
Even if his behaviour was put down to his personailty disorder - the continuation of his late childhood display - it would be to recognise what situations that this might get him into, that would allow his schizophrenia to take over.
There was never time to take a long view of his 'community' behaviour i.e. with others, rather than with the authoritative staffing and hostel boundary regulations.
His hospital stay had not tested him and prepared him for a transfer to regular work, or other regularising ocupational activity, which would allow for observation on a more normalising social situation.
A potential to go wrong was the comparitively low dosage of the medication - the internal level could quickly be dropped below the therapeutic level.
The final permanent fact to be always there, was the manner and matter of the earlier homicide. He bullied someone who was weaker, as he used to do growing up, but here he also was in a world of schizophrenia, that got to the point of manslaughter before it was taken into treatment.
Added to the strong family history and the type of illness in the family story.
I miss in the Inquiry Panel report the intevention form the RMO, and the Care co-ordinator by their prsence giving backing to the Hostel boundaries
I may have missed it in a two volume 1000 pages or so.