|
oh, what a fall was there
| 1.3 At the time of the killing SP was a patient of South West London and St George’s Mental Health NHS Trust (hereafter referred to as “the trust”). He was first referred to the trust by his general practitioner (GP) in April 2004. He had two episodes of inpatient care at Springfield Hospital. His care and treatment in the community was provided by a specialist community mental health team (CMHT) known as the early intervention service (EIS) which cares for patients experiencing the early stages of psychotic illness.. Background to the homicide. 1.4 SP was born in 1976. He is a black British man. His family is of Caribbean origin. SP was raised by his mother. He was described to us as having a normal childhood. He did well at school and attended church regularly. He began to smoke cannabis at the age of 14.. 1.5 After leaving school SP attended Northampton University where he studied for a degree in law, business and politics. He left university at the end of his second year to earn money. He lived briefly in a flat in north London but returned to live with his mother in early 2004.. 1.6 In April 2004 SP’s GP referred him to the East Mitcham CMHT and he attended an outpatient appointment in May 2004. He was seen briefly and a referral was made to the EIS. In June 2004, before his assessment by the EIS, he was sectioned under the MHA and admitted to the trust’s Springfield Hospital. He absconded a week later. After a disturbance at a local church he was readmitted under section in July 2004. 1.7 During this admission to hospital and during his subsequent admission SP was violent or aggressive on a number of occasions.. 1.8 After responding well to treatment SP was discharged in September 2004 into the care of the EIS. He was cared for on the enhanced level of the care programme approach (CPA). His care coordinator was Neil Hickman who was also the EIS team manager. 1.9 He remained in contact with the EIS, but he was reluctant to address his mental health problems and refused psychiatric medication. In January 2005 SP moved from his mother’s house into low support accommodation at Links Road in Tooting.. 1.10 In April 2005 SP flew to Jamaica to visit relatives for two weeks. He became psychotic while he was there.. On his return and in response to concerns about his mental state, Neil Hickman and a colleague, community psychiatric nurse (CPN) Sanjaya Warnatilake, visited him at his mother’s house. During the visit, SP seriously assaulted Sanjaya Warnatilake. The police were called and SP was taken to hospital. SP was placed under section 3 of the MHA.. In June 2005 he was again discharged into the care of the EIS.. 1.11 From June 2005 until he killed Matthew Carter, SP’s engagement with the EIS became increasingly limited and he continued to refuse psychiatric medication. In autumn 2005 he began a university course in London. Neil Hickman saw him face-to-face for the last time on 8 December 2005. Between then and the killing of Matthew Carter, the EIS had some telephone contact with SP and his mother.. 1.12 On 8 February 2006 SP was arrested in Croydon and charged with a motoring offence. At the police station he was agitated and upset. He was seen by a Forensic Medical Examiner... (FME)police surgeon who concluded that SP was not psychotic and later that evening he was released on bail.. 1.13 In the week before the killing of Matthew Carter there was further telephone contact between the EIS and SP and his mother. Late on the night of 18 February 2006 SP’s brother and uncle took him to his mother’s house.. SP killed Matthew Carter on the night of 18/19 February 2006. He was charged and later convicted of manslaughter on the grounds of diminished responsibility and was ordered to be detained in hospital under section 37 of the MHA coupled with a section 41 restriction order without time limit.. 'We found that the EIS does not comply with the DH’s policy implementation guidance (PIG) in that its size makes it unable to meet the needs of the population of the three boroughs, it does not provide out-ofhours cover and it does not have dedicated inpatient beds.. Neil Hickman, the EIS team manager was SP’s care coordinator. Neil Hickman was unduly focused on the wishes and desires of SP and his family rather than on the risks he posed when unwell, and that Neil Hickman’s failure to ensure that a face-to-face mental health assessment of SP was undertaken in February 2006 was a professional mis-judgment. . We considered SP’s attack on Sanjaya Warnatilake on 20 April 2005. This was a particularly serious incident that caused acute injury and continuing distress. We were concerned to discover that witness statements were not taken until three months after the event. The Crown Prosecution Service (CPS) decided eventually not to prosecute SP for the attack. Although it was not for us to consider the merits of that decision, we found that a prosecution might have been beneficial for the treatment of SP for a number of reasons, including that it might have encouraged him to address his condition and engage with treatment. <.BR>The issue of the attack on Sanjaya Warnatilake demonstrated the need for the trust to develop and maintain close working relations with the police and the CPS. It also demonstrated the need for the senior management of the trust to be aware of serious incidents involving trust staff so that they can offer staff appropriate support. SP’s mother LP was actively involved with her son throughout the period that he was known to the trust. We found that there was regular communication between LP and the EIS however there was an over reliance on her as the means by which the EIS monitored SP’s progress. She was not adequately equipped to fulfill that role or to act in her son’s best interests. In February 2004 SP moved into accommodation managed under Merton Borough Council’s supported housing scheme. We found that SP’s carer under that scheme did not provide the level of care that she was contracted to provide. We also found that the EIS did not adequately inform the carer of SP’s mental health issues and the potential risks that he posed. Nor did the EIS take the opportunity of using the carer as a means of engaging SP and monitoring his mental health. the need for such an assessment was made absolutely clear after SP’s arrest for driving offences on 8 February 2006. “ mission by consultant ... !!! We would work with people, and instead of saying: ‘This is what we think you need’ we would start by saying: ‘What do you want us to do? We will start with that and around that build trust and engagement.”. The EIS operates from Monday to Friday between 9am and 5pm. The Merton, Sutton and Wandsworth crisis service provide cover at other times via a free phone number called Crisis Line. The crisis service directs patients and their carers to the services available outside the hours that the EIS operates.. “felt at the start that if we were going to be truly multidisciplinary, and if we were going to be truly non-hierarchical we must all do similar things, and that involved also sharing expertise and learning, so we did not feel that somebody’s role was too precious”.. While SP was under the care of the EIS, the team as a whole held a meeting, known as the multidisciplinary team meeting, each Monday morning. It began with a discussion of current casework issues, in particular: . The meeting would then move on, on a rotation basis, to either a session for peer supervision (an opportunity to consider certain more difficult cases in greater depth), or the EIS team business or an education session. A further meeting on Thursday mornings ensured that issues relating to the “acute list” were resolved before the weekend, when the EIS did not operate. The Thursday meeting was not as well attended as the Monday meeting because some staff worked part-time.. On the basis of his interview with SP and LP, Dr Ovens diagnosed SP as suffering from an acute psychotic illness.. CMHT consultant referral to early Team It is in the Code of Practice of the Mental Health Act that one should treat with the least restrictive option […] we want that initial contact, which can shape a person’s future pattern of engagement with services, to be as least restrictive as possible.”. Sunday 6 June 2004, while SP was at his grandmother’s house, he jumped out of a window. LP told us that this led her and other family members to try to have him detained under the MHA that evening. LP told us that she had contacted the social services for that purpose but they had been unable to proceed because the police did not attend.. SP was assessed by Earl Lewis, an ASW and Dr Dewsnap, who recommended an emergency detention under section 4 of the MHA. SP was agitated at the time of the assessment and admission to hospital and had to be restrained by police, with whom he struggled violently. LP said seeing her son restrained and taken away to hospital was extremely traumatic. She told us: “It really devastated me.” . SP was admitted to the PICU at the trust’s John Meyer ward at Springfield Hospital and placed in seclusion.. 7.10 SP’s section 4 was converted to section 2 of the MHA on 10 June 2004. SP’s section 4 was converted to section 2 of the MHA on 10 June 2004. on what grounds ?. 7.11 On 12 June 2004, Dr Parimala Moodley, the consultant psychiatrist for the PICU, undertook a review of SP. She prescribed medication for his psychotic and affective symptoms in the form of Olanzapine 10 mgs, daily. Absconded In the same report Dr Moodley refers to SP having admitted to smoking two joints of cannabis per day but recently increasing his use of cannabis to more than this.. mother covered up on contacts The police were called and they took SP back to the John Meyer ward. They told ward staff that while at the church SP had “pulled out a door” and “restrained the Pastor”.. SP’s section 2 of the MHA expired on 4 July 2004. Next day he was put on section 5(2) and later that day this was converted to section 3. The medical staff assessed him as presenting a high risk of absconding, of harm to himself and others, non-compliance with medication and deterioration of his mental health.. [SP] clearly not currently detainable under Mental Health Act, and consent to treatment is due so has to be taken off section…”. 7.29 13 August 2004 Dr Dewsnap prescribed depot antipsychotic medication. SP was transferred back to the PICU on John Meyer ward for a period to monitor his reaction to the depot medication. He went back to Jupiter ward again on 19 August 2004. several aggressive and violent attacks recorded .
7.25 On 6 September 2004 Dr Trevor Chan, SHO, and Julia Heathcote, occupational
therapist, both members of the EIS team, attended Jupiter ward to undertake an
assessment of SP. Dr Chan states in his note of that meeting that SP was “aware that he
had had a severe episode of distressing experience, but puts it down to his over
enthusiasm in his religious beliefs, rather than seeing it as an illness”. However [SP] has been clear that he will not take medication unless legally compelled (i.e. detained) and therefore his mental state requires close monitoring in the community…. “LP mentioned that [SP] had been using cannabis again due to boredom - does not want [SP] to know she has told me”. Neil Hickman recorded his plan as “? Provide emergency supply of medication”.. Neil Hickman, CC ASW Team manager ...as well as working to address SP’s housing and vocational needs, undertook a significant amount of work, particularly during the autumn of 2004, to deal with SP’s chaotic financial affairs. He secured income support payments for SP and resolved claims against SP by at least four firms of bailiffs in respect of unpaid parking and road traffic fines and unpaid phone bills. Neil Hickman also engaged in long correspondence that went on well into 2005, in respect of an unpaid overdraft. He applied to the social fund on SP’s behalf for financial help with furnishing the accommodation at Links Road and for clothing.. [SP] and mother have Crisis Line numbers etc.”. On 21 December 2004 Neil Hickman phoned LP. She was still concerned and angry because SP was “staying in bed all day”. She had no additional concerns.. Neil Hickman spoke with LP again on 18 April and she reported clearer signs that SP was unwell, including talking to himself and being verbally hostile.. It was evident to Neil Hickman and Sanjaya Warnatilake that SP was acutely psychotic. He was mute, glaring in a paranoid manner, clutching his chest and jabbing his fists in the air. Neil Hickman and Sanjaya Warnatilake tried to engage SP and to encourage him to take medication. They withdrew with a view to arranging a MHA assessment. SP followed them into the front garden and launched a flying kick at Sanjaya Warnatilake’s jaw, causing him to bite his tongue and mouth and sustain cuts around his jaw and pain in his neck. Sanjaya Warnatilake made clear to us that the attack was highly aggressive and unprovoked. After the attack on Sanjaya Warnatilake, the police were called. Dr Singh also went to LP’s house and on Dr Singh’s recommendation SP was detained under section 4 of the MHA and taken to the PICU at the John Meyer ward of Springfield Hospital.. A hostile crowd in the street jeered at the police. [ SP is black ] admitted SP diagnosed an acute psychotic episode and a relapse of paranoid schizophrenia.. section 3 of the MHA. LP at first objected to the detention but on 22 April 2005 she withdrew her objection and the section 3 process was completed..
7.64 SP was involved in a number of incidents of violence or aggression during this
period of detention as an inpatient: At Dr Dewsnap’s ward round on 20 May 2005 it was decided to hold a section 117 meeting to plan SP’s aftercare on 27 May 2005. 7.71 On 27 May 2005 the trust’s MHA office gave notice to Dr Dewsnap that SP had applied to the MHA Tribunal to be discharged from detention and that the tribunal had been convened for 27 June 2005. The notice also reminded Dr Dewsnap that his report on SP had to be received by the MHA office no later than 6 June 2005..
7.72 Dr Dewsnap and his team, SP and LP and Dr Brock Chisholm, a clinical psychologist
with the EIS attended the section 117 meeting held on Friday 27 May 2005. Dr Chisholm
covered for Neil Hickman, who was on holiday. Dr Balabhadra’s note of the meeting shows
that SP’s mental state was deemed to be stable. On 6 June 2005 SP was seen at Links Road by Dr Krishnan and Dr Chisholm. SP was calm and cooperative. He spoke about God talking to him and feeling that his thoughts were being read. He felt he did not need medication as he could prevent his illness without it but was willing to accept his depot injections “for the time being”.. In the event of evidence of relapse then [SP] should be formally assessed under the MHA at an early stage, is likely to require police involvement to contain any risk to others. He was agitated and upset at the police station, where he punched a cell door. He was seen by the duty FME, Dr Felicity Nicholson, in the company of LP LP told Dr Nicholson “[SP] is doing well, I’m pleased with how he’s doing, he’s been stable and he’s eating well and studying”. Dr Nicholson concluded that SP was not psychotic and did not ask the emergency duty team to attend for a MHA assessment.. 9 February 2006 LP rang Neil Hickman and told him about the events of the day before. According to Neil Hickman’s note of that conversation, LP maintained that SP had early signs of relapse, that he was distracted and talking to himself but able to function and contain the signs when seen by professionals. The note also states that LP was absolutely opposed to admission to hospital. She asked for a prescription so that SP’s brother could try to persuade him to take medicine.. Panel review . When the EIS was established and while SP was a patient, the care coordinators’ caseload was kept to 12 patients each. However, subsequent pressure on the service meant that the EIS care coordinators had to agree to increase their caseload to 15. Neil Hickman told us that notwithstanding this increase in individual caseloads, waiting times for the EIS had risen over the previous year to about three months. Neil Hickman said this waiting time generated “a lot of external pressure and frustration for the CMHTs”. Given the purpose and aim of the EIS, which is principally to initiate effective treatment for psychosis at the earliest possible stage, we agree with Neil Hickman that a waiting list for that service “defeats the object a little”.. The trust has issued instructions to team managers as a result of a number of recent investigations into untoward incidents at the trust that they should hold no more than five cases. Neil Hickman told us that he had been trying to reduce his caseload in line with those instructions.. no black members of the EIS staff since the end of 2003 although a high proportion of EIS patients are young black men. Some members of the EIS acknowledged to us that having staff members from an African or Afro-Caribbean background might have advantages with patients who exhibit difficulty in engaging with white mental health professionals.. Dr 63 Singh also said that decision and Dr Dewsnap’s failure to discuss it directly with him had made him “cross”.. “There are issues for our client group, given that they are likely to be around much older patients, possibly patients with much more chronic conditions. A lot of EIS models and papers talk a lot about engendering optimism in people, and the inpatient settings can have the opposite effect and it gives quite a bleak message as to what the future holds.”. 8. We visited visit John Meyer and Jupiter 9. We find that the shortcomings we identify in the present provision of inpatient facilities for the patients of the EIS indicate the need for dedicated EIS beds.. They show that he appeared on the “acute list” for a significant part of the time he was under the care of the EIS. Dr Singh acknowledged to us that SP was one of two cases the EIS team discussed most frequently.. She explained “I didn’t agree but I didn’t disagree because I didn’t want to be the one to section him. I left it to them because I felt that it would have been another pressure on me and I would have to live with the fact that I got him sectioned”.. 9.7 LP’s ambivalence towards the mental health services and their treatment of SP appears principally to have resulted from her fear of damaging her relationship with him, and from her own anxieties about his being detained in hospital. It may also have stemmed in part from a failure fully to understand, or an unwillingness to acknowledge, the nature of his condition. Ah trust again. I don’t think to this day it was really explained to me […]”.. 9.8 Neil Hickman denied to us the suggestion that he had not explained to LP the nature of SP’s illness and its implications.. In particular, a CPN might have had more resources to draw on in offering training to LP about SP’s condition and mental health issues. Recommended the EIS should consider whether it would be appropriate for the patient to be joint-worked by two care coordinators while remaining the responsibility of a single named care coordinator for CPA purposes.. The EIS should have an external peer review system, available in all cases thought likely to benefit from it, regardless of whether, or for how long, the service user in question has been in the “red zone” (the acute list).. We agree with the view of Dr Singh and other members of the EIS team, that in the circumstances it would have been beneficial to SP’s treatment if, after his inpatient treatment, he had remained under section but had been granted extended leave of absence under section 17 of the MHA rather than being discharged from the provisions of the MHA. Dr Singh outlined the benefits of such a course of action as follows:. Dr Dewsnap told us he would have liked to extend the time that SP was given leave in the community subject to the restrictions of section 17 of the MHA but he felt that there was a strong likelihood of SP’s appeal being successful and that, in effect, his hands were tied by the MHA. Tribunal might have influenced SP an LP . But Neil Hickman said he was in fact never able to make real progress in getting SP to acknowledge his mental health issues, including the need for him to take medication and consider early warning signs of relapse. . There were no face-to-face meetings between Neil Hickman, or any other member of the EIS team, and SP after 8 December 2005. . Dr Singh described to us the particular difficulties he felt LP had in dealing with mental health services. He referred to the fact that she wanted to tell services about SP’s progress and mental state but was worried about how it would affect her relationship with him. Equally, LP was distressed by seeing SP detained by police under the MHA. This too gave her a dilemma about what to tell mental health services. Dr Singh told us that these are common responses for the relatives of service users. He said: “the families can’t . Neil Hickman put her in touch with the Merton carers group, but she told us its meetings gave her bleak insights into mental illness and she found them depressing. The clinical notes disclose too that Neil Hickman gave LP a copy of the carers assessment form, during a home visit with SP on 17 November 2004. The carers assessment form is a simple list of questions for completion by the carer. Neil Hickman could not recall what LP said at that. There is no evidence that Neil Hickman, or anyone else from the EIS spent any dedicated time alone with LP talking through and considering her needs or, once she became the major link between SP and the EIS, considering with her what support she might need to fulfill that role. 9.36 We believe that LP should have been the subject of a planned programme of work, including dedicated time alone with EIS staff, aimed at developing her understanding of SP’s mental health issues and ensuring that she had adequate support to fulfill her role as SP’s carer and later as the principle link between SP and the EIS. . We are concerned that there was no documentation in SP’s CPA of the role played by LP and the risks associated with it. We find that the reliance the EIS placed on her from the autumn of 2005 to maintain its contact with SP was a significant feature of his care plan and should have been made explicit in his CPA plan. There should also have been documentation of the steps to be taken as part of the care plan to ensure that LP was adequately briefed and supported to fulfill her role as the main point of contact between the EIS and SP.. The trust should remind staff of the need to ensure that CPA documentation gives a comprehensive outline of a patient’s care plan, and where necessary the plan should set out the role to be played by carers and any support they may require.. the case for undertaking an assessment, if necessary under the powers of the MHA, became absolutely clear after the telephone conversation that Neil Hickman had with LP on 9 February 2006.. 9.55 Neil Hickman was told on 9 February 2006 of the events of the previous day in Croydon, including the fact that SP had resisted arrest. LP also told Neil Hickman that SP had “got signs of relapse – distracted, talking to himself at times but able to function and contain this when seen by professionals”. She requested a prescription for SP. We know from the evidence of Neil Hickman and Dr Singh, referred to elsewhere, that LP was considered to be reliable in alerting the EIS to concerns about SP’s health, but liable to play matters down if she thought there was a danger of admission to hospital. Accordingly, we believe that her concerns should have been taken as strongly indicative of a relapse.. NH ' One that LP didn’t want us to do that because she thought it would tip [SP] off about her communication with us, and we had some uncertainty about how safe it was to do that.. unduly focused on SP’s own wishes and desires and those of his family rather than on the risks he posed to himself and to others when he was unwell.. We are critical of the fact that there was no face-to-face assessment of SP in the 10 weeks prior to 18 February 2006. We believe that the failure to undertake a mental health assessment on or after 9 February 2006 was a professional misjudgement by Neil Hickman as SP’s care coordinator and by Dr Jonsson who was providing day-to-day medical input to the EIS after his return to work on 12 February 2006. We cannot say for certain that if a mental health assessment had been done it would have resulted in SP’s detention, but the failure to undertake an assessment means the EIS may have missed a potential opportunity to detain SP and so avert the tragic events of 18/19 February 2006. Dr singh after retiring !!!! and out of it.“ This is one of the trickiest dilemmas we have in applying section 3, and I have seen a lot of patients who are clearly deteriorating and the families are concerned but they are told he is not ill enough to be detained, and things have to get worse before the person can be detained. Over the years I have changed my approach to this, and I have felt that the Mental Health Act allows us to detain people, even if they are not fully floridly psychotic, and the criterion is the risk of deterioration […] the absence of absolutely florid psychosis would not have been the sole determining criterion in my mind. I might have said, ‘something is shifting, and we know how quickly he becomes unwell, and there is risk of deterioration, let’s go for a section’. But I am guessing, I am not certain I would have done that, and my second opinion colleague may not have agreed, the social worker may not have agreed. My threshold generally is lower for the Mental Health Act.” Chris Stanger told us there were more than 250 assaults each year in the trust of which about 40 to 50 are reported to the police. This creates a large workload for the trust staff responsible for advising on and pursuing prosecutions. .
|