THE INSTITUE OF MENTAL HEALTH LAW

SUMMARY FROM THE BULLETIN OF
THE INSTITUTE OF MENTAL HEALTH LAW

APRIL 2005


I will hurt someone …, Halifax Today, 16th March 2005
A teenager told psychiatrists she was out of control and had the urge to hurt others just months before she killed her boyfriend, an inquiry has found. Despite the revelation, teamed with a history of self harm and violence towards others, psychiatrists concluded Jayne Coulter was of “no immediate risk to herself or others”. Coulter, of Mixenden, Halifax, was 19 when she stabbed 18-year-old Nathaniel Lees to death at their home in Clough Lane. She had had psychiatric problems since she was 13. But an independent inquiry into the case said failings in the system found her notes were not collated into one file, meaning doctors did not know her full mental history. Failings included not making a formal risk assessment and Coulter having to wait six months for an appointment that was deemed urgent. Experts differed about the diagnosis and because this wasn’t resolved risks were increased, said the report. When she stabbed Nathaniel, Coulter was under the care of South Yorkshire Mental Health Trust. After admitting she could end up hurting others in December 2001, Coulter was “urgently” referred to the clinical psychology service for a second opinion. But no appointment was available until June 2002. She killed Nathaniel on April 1, 2002.

Coulter was jailed for life in February 2003 after admitting manslaughter on the grounds of diminished responsibility. She stabbed Nathaniel several times with a kitchen knife. She began seeing the child and adolescent psychiatry services when she was 13. She first came to the attention of adult services in November 2001 after an overdose. She was referred to the self-harm team and a locum consultant psychiatrist and was seen in December 2001. In March 2002 she took another overdose and was assessed by a duty doctor, who only had her case notes, and discharged. The inquiry was commissioned by West Yorkshire Strategic Health Authority. Its author Dr Simon Baugh, a medical director for Bradford NHS Care Trust said: “There is a requirement for anyone in contact with secondary psychiatric services to be subject to the Care Programme Approach, and in this case an Enhanced Care Programme would be appropriate given the multiple services involved and the risk of self harm which was obvious in this case. This must be seen as a failure of the system. There is no evidence anywhere in the documentation of a formal risk assessment beyond a simple statement of no risk, this in spite of several presentations of self harm, the client herself stating she was out of control with urges to harm others, and recorded evidence of violence towards others (especially her boyfriend) which on two occasions during her contact with the service involved the police. The statements in the notes of ‘no immediate risk of harm to herself or others’ was not evidenced and contrary to the history.”

A number of recommendations are now being implemented. Patients of specialist mental health services will now be subject of a care programme with a care-co-ordinator and formal risk assessment. There will be single case notes and a review of the system which prioritises referrals.

Coulter could be free in seven months. In February 2003 the judge said she would be eligible for parole after two years and eight months.

Report
http://www.imhl.com/members/pdf_files/Coulter.pdf

Action plan
http://www.imhl.com/members/pdf_files/Coulteraction.pdf






Inquiries / Reviews: being sought or underway


Anthony Hardy

Ripper victim: I’ll sue for justice over attack, Hampstead and Highgate Express, 18th February 2005
A former masseuse who was raped and nearly killed by Camden Ripper Anthony Hardy is attempting to sue the Crown Prosecution Service. Tina Harvey was this week called to speak at the independent inquiry investigating the mental health care Hardy received before his killing spree in December 2002. After giving evidence at Portland House, in Victoria, on Wednesday Ms Harvey told the Ham&High the CPS has never taken her case seriously. Hardy, 53, made an appointment to visit Ms Harvey at her Northampton home on December 13, 2002. She said: "I was a professional masseuse and Hardy came to me for a professional massage. I did not offer him sex and he attacked me." She reported the attack in January 2003 after Hardy had been arrested for murders committed at his flat in College Place, Camden Town. Hardy has never been prosecuted for his attack on Ms Harvey, who recently launched campaign group Safety of Sexworkers UK. She said: "They didn't take it on because he has got three life sentences so why bother? Because I have been campaigning since 2001 to bring changes to the UK sex laws I personally believe that I have been denied my right to go back to court. I now have a new appeal in for legal aid to sue the CPS for not charging Hardy." She gave evidence at the inquiry along with Jackie Valad - the mother of Elizabeth Valad, one of Hardy's victims. Both women appeared at the High Court last month in a failed bid to get a public inquiry into the case.

Ms Harvey said: "My main question to them was why was Hardy released from St Luke's (mental health hospital in Muswell Hill)." Hardy was jailed for life in November 2003 after pleading guilty to the murders of Elizabeth Valad, Bridgette MacClennan and Sally White. He was originally sectioned in March 2002, shortly after the body of Miss White was found at his flat. Her death was initially treated as "natural causes" and Hardy was allowed to leave St Luke's in November 2003. Within a month he killed Miss Valad and Miss MacClennan, whose dismembered body parts were found in his flat and in bins near his home. The independent inquiry examining the services Hardy received from organisations including Camden Council and the Camden and Islington Mental Health and Social Care Trust started in the summer. A CPS spokeswoman said: "This further allegation came to police after Anthony Hardy had been arrested for the murders. It was reviewed thoroughly but it was considered there was insufficient evidence to prosecute Anthony Hardy for that particular allegation." She said the decision had been reviewed by two independent counsel and the director of serious case work in London.


Camden Ripper victim takes fight to election, This is Local London, 6th March 2005
A surviving victim of the Camden Ripper' plans to stand in the general election in a desperate bid to get her case against the serial killer reopened. Tina Harvey, a former masseuse and mother-of-two, claims Anthony Hardy raped her and tried to kill her on December 13, 2002, at her Northampton flat, weeks after he was released from St Luke's, a psychiatric hospital in Muswell Hill. Hardy murdered two prostitutes and dumped their mutilated bodies near his Camden home two weeks later. He was jailed for life in November 2003 but Ms Harvey is still fighting for her case to be heard. The 40-year-old says the police and Crown Prosecution Service (CPS) dropped her case once Hardy pleaded guilty to murdering Elizabeth Valad, Bridgette MacClennan and Sally White. "Just because he has three life terms does not mean I am not entitled to my day in court," she said. "People have no idea of the nightmare I have been through. I deserve justice and funding to fight my case, but every avenue has been blocked." Police and the CPS have confirmed they investigated Hardy for three other rapes, including the case of Ms Harvey, but decided there was insufficient evidence to secure a conviction. This week she expects to hear if her third bid for legal aid this time to sue the CPS for not charging Hardy has been successful.

Ms Harvey, a grandmother, hopes to stand against Tottenham MP David Lammy in the coming general election as a protest, because he is a Parliamentary Under-Secretary in the Department for Constitutional Affairs, which is responsible for legal aid. Doctors released Hardy from St Luke's in November 2002 after judging that he posed no threat to the public. He had already murdered Sally White, whose death was wrongly put down to natural causes after her body was discovered in his flat in January 2002. At Hardy's sentencing in November 2003, the court heard that he was released from care despite warnings from psychiatrists and other health experts that he was a danger to women.
A North Central London Strategic Health Authority inquiry into the treatment received by Hardy leading up to the murders in December 2002 is expected to publish its findings shortly. Ms Harvey gave evidence to that inquiry last month. She plans to protest outside the psychiatric hospital in Woodside Avenue when the findings are announced.


‘Camden Ripper’ report out next month, Hampstead and Highgate Express, 10th March 2005
The date for the publication of a report into the treatment and care of triple killer Anthony Hardy will not be known until next month. The independent panel examining the case has finished gathering evidence and is currently compiling its findings. A spokesman for the North Central London Health Authority said: "They have finished evidence gathering and are compiling the report making sure everything is factually correct." Hardy was jailed in November 2003 after admitting to murdering and dismembering prostitutes Sally White, Elizabeth Valad and Bridgette MacClennan at his flat in College Place, Camden Town. In March 2002 he was sectioned under the Mental Health Act but was allowed to leave St Luke's Hospital, Muswell Hill, in November. Within weeks he had embarked on a killing spree.


‘My friend turned out to be Camden Ripper’, Hampstead and Highgate Express, 18th March 2005
A woman who befriended Camden Ripper Anthony Hardy in a mental health hospital believes she could have been his fourth victim. Sarah McGuinness, 52, who shared a ward with Hardy at St Luke's Hospital, in Muswell Hill, also claims she was not allowed to give evidence at the recent independent inquiry into his hideous crimes. Ms McGuinness had no idea the police had previously discovered a dead body in his Camden Town flat when she became friends with Hardy, who helped her research her family tree. She said: "I was basically overawed by him because of his size but I thought I must not be prejudiced. He was very helpful. After I left he wrote to me quite a lot and visited my flat. I didn't know about his history. I just thought he was an alcoholic. They didn't warn me or I wouldn't have gone anywhere near him." It was only after Hardy was allowed to leave the ward and went on a killing spree that Ms McGuinness became aware of the danger she had been in. "I was shocked when I found out about it," she said. "When he was on the run I was frightened that he might come round to my flat, but he didn't."
Two years on from Hardy's crimes and Ms McGuinness has only just received counselling. She is also still waiting to be re-housed from her flat in Baynes Street, Camden Town. She said living so near to Hardy's College Place Estate flat and just yards from the spot where the dismembered body of another murderer's victim, rabbi Andreas Hinz, was discovered, has left her traumatised.

Ms McGuinness, who has a history of mental health problems, wanted to speak at the recent independent inquiry about the treatment patients received at St Luke's, where she claims a male member of staff went on drinking binges with Hardy. She said: "I don't think they wanted to open a can of worms about community care. I wanted to speak but they wouldn't let me." A spokeswoman from the North Central London Strategic Health Authority, which commissioned the independent inquiry along with Camden Council, said: "Ms McGuinness wrote and offered written information before Christmas which the panel accepted. The panel acknowledged receipt and said they would take the information into account in the assembling of their report." A spokesman from the Camden and Islington Mental Health and Social Care Trust, which runs St Luke's, said: "We categorically deny the allegations that a member of staff went on drinking binges with Hardy. He is not on the staff anymore but it has nothing to do with the Hardy case. His contract came to an end and that's that. He left just like other people do."








John Barrett

Hospital that let out killer has history of fatal errors, The Telegraph, 2nd March 2005
A psychiatric hospital that let out a violent schizophrenic who then stabbed a cyclist to death has a history of management failures which resulted in at least four other killings by patients, The Telegraph can disclose. John Barrett, 42, who pleaded guilty last week to the manslaughter of Denis Finnegan, 59, had been allowed out on "ground leave" by Springfield hospital in Tooting, south London, even though he had a record of mental illness and violence. He was told to return within an hour, but went to a DIY store, bought a set of kitchen knives and attacked Mr Finnegan as he rode his bicycle in Richmond Park, last September. Barrett was allowed out despite the fact that at least four other Springfield patients have killed people in the past 13 years.

The South West London and St George's Mental Health Trust, which runs the hospital, was criticised in an independent report published in 2000 for "serious management and systems failures", after one patient, Anthony Joseph, was set free and went on to kill Jenny Morrison, his social worker. Ms Morrison was not told by hospital authorities that Joseph, a paranoid schizophrenic who believed he was the son of God, had already threatened staff, had a conviction for carrying a knife and had a history of sleeping with a machete under his pillow. Nor was she informed that Joseph claimed to be plagued by "demons" and that he had said she would be "brave" to see him. As a result, she visited him alone in the hostel where he had been living since his release. Within minutes, he had stabbed her more than 100 times. When Joseph was discharged from Springfield hospital, he was given no written care plan, no risk assessment or systematic monitoring of his medication and no outpatient follow-up.

Other killings carried out by Springfield patients include that of Mamade Chattun, a nurse beaten to death by Jason Cann in 2003. Earlier this month, Cann was convicted of manslaughter on the grounds of diminished responsibility. The Trust's report into the incident is due to be published shortly. The killing took place on the day Cann was admitted, yet he was left alone and unobserved in the ward's lobby area, which should not have been used by patients, despite having attacked a social worker earlier and refusing to take his medication.
In 1993, Mark Ricketts stabbed Mark Kemp repeatedly in a Tube station, months after being released from Springfield. Mr Kemp, who had more than 20 stab wounds, survived only because the blade of the knife bent during the assault.
Two years earlier, John McCormack stabbed his father, Thomas, to death within minutes of running away from Springfield, where he was a voluntary patient. He was convicted of manslaughter and committed to Broadmoor high-security psychiatric hospital indefinitely.
Tim Loughton, the shadow minister for mental health, said last night: "These incidents raise question marks as to the procedures being followed at Springfield hospital for people who clearly need treatment. My fear is that the liberty of people with serious mental illness is being driven by the lack of available services for them rather than their clinical need."


Ocean crime scene, icWales, 3rd March 2005
Ocean Colour Scene frontman Simon Fowler has talked for the first time about his encounter with killer John Barrett, who last month was convicted for the murder of ex-banker Denis Finnegan. Barrett, a former mental health patient, was arrested in Richmond Park in London on suspicion of murdering cyclist and retired banker Denis Finnegan on September 2 last year. That same day singer Simon was taking a break from recording the band's new album A Hyperactive Workout for the Flying Squad and was walking his dog in the same park. Barrett had approached him and uttered the words "Stay lucky", before walking off. "Of course I was automatically uneasy at someone approaching me with such a weird comment," says Simon. "But it was only after I heard the news on the radio that it dawned on me this was possibly the person the police were looking for. I was in total shock when I realised. The whole incident has made me reflect on my life and I now realise how incredibly lucky I am to be with a band I love, with the support of fans. It's very humbling."




Care failings left schizophrenic free to kill cyclist, The Telegraph, 23rd March 2005
A paranoid schizophrenic released into the community without adequate care was jailed for life yesterday for killing a stranger as he cycled through a park. A requirement of John Barrett's release was that he saw a psychiatrist at least once a month. But, the Old Bailey heard, there were periods last year of 10 weeks, 13 weeks and 11 weeks when he was not assessed by a consultant. During that time his condition deteriorated, he took cannabis, which led to "psychotic episodes", and he heard voices telling him to kill. Barrett was sentenced for killing Denis Finnegan, a 50-year-old former banker, with a kitchen knife after ambushing him in Richmond Park, south-west London, last September. Judge Anthony Scott-Gall told Barrett, 41, he would serve more than 15 years before being considered for release. Barrett, once a promising singer until he succumbed to drugs, crime and mental illness, was taken from the court to Broadmoor. The judge told him: "This was a planned and unprovoked attack on a completely innocent member of the public."
Barrett, from Putney, south-west London, had pleaded guilty to the manslaughter of Mr Finnegan, who had worked for the Royal Bank of Scotland, on the grounds of diminished responsibility. In mitigation, Merida Harford-Bell said if it had not been for "failings" by the mental health services Barrett might never have been free to kill. Between September 2002 and October 2003, he was in a secure unit at Springfield Hospital in Tooting after being convicted of a knife attack on two patients and a nurse at nearby St George's Hospital. He was conditionally discharged by a mental health review tribunal but after that "there were huge gaps between him seeing, in particular, his consultant or anyone medically qualified", Miss Harford-Bell said. During this time his partner, Jane Whittaker, became seriously worried about him. On Sept 1 last year, Barrett returned to Springfield as a voluntary patient but was given an hour's ground leave despite not even having been assessed by a consultant. He discharged himself and the police were called, although the risk Barrett posed was not "spelt out" to them, Miss Harford-Bell said. Mr Finnegan's brother, John, said: "I am appalled that there were people crying out to get help on his behalf and nothing was done." He said he was very disappointed that he had not had satisfactory answers after writing to Tony Blair.



James Smith

McConnell’s inquiry call on mentally ill patient who killed, The Herald, 15th March 2005
Jack McConnell last night called for an inquiry into the release, formally sanctioned by himself, of a psychiatric patient who went on to kill a man. James Smith, a conditionally discharged restricted patient, pleaded guilty at the High Court yesterday to culpable homicide on the grounds of diminished responsibility. He was made subject to an interim hospital order to allow for further reports, and the case will return to court for sentencing on June 2.
Stuart Robertson, 37, the victim, also had a history of mental illness and was, briefly, a restricted patient himself.
His body was found on October 22 last year in a car park at the rear of Pollok House, in Pollok Park, Glasgow, where it had lain since the previous night.
Smith's release from secure accommodation had to be approved by the first minister, which was granted conditionally about 18 months before the killing. He had been in care from about 1997 to 2003.
Mr McConnell now wants the Mental Welfare Commission to review the handling of the case.
Smith's release would have been agreed only on the recommendation of the patient's client team, including the medical officer responsible and the executive's own psychiatric officer.
However, Mr McConnell's name would have been on the release order and high-profile killings by psychiatric patients can result in a serious political backlash, even though the majority of homicides are carried out by the clinically sane. A spokesman for the executive said: "The first minister has invited the Mental Welfare Commission to carry out an inquiry into whether all that could have been done to monitor the risk Mr Smith posed in the community was done, and to identify any lessons which might be learned for the care and treatment of other patients."


Judicial review, Your letters, The Herald, 18th March 2005
Mr McConnell has asked the Mental Welfare Commission to review the handling of the case of James Smith who killed a man while a restricted psychiatric patient on leave in the community (March 16). The role of the MWC is to exercise a general supervisory and protective function for psychiatric patients, especially those who are legally detained. While the commission does investigate complaints about treatment, it is not an organisation that can provide the level of review needed in this instance. The MWC is nominally independent but receives public funding, is administered by the Civil Service and has no powers to compel witnesses to give evidence. It has a loud bark but no bite.
The commission is not the proper authority for this investigation where the roles of the first minister and his medical advisers are to be scrutinised. I hope that the MWC declines to be involved and that the executive asks for a judicial review or commissions an assessment by an independent inquiry team that might include a QC and medical assessor with no executive, Civil Service or NHS connections.

Dr George Dodds, Bridge of Allan.


Peter Bryan

Psychotic killer was released against Home Office advice, The Times, 16th March 2005
Police officers were horrified to discover Peter Bryan calmly frying human brains on a stove with the dismembered body of his victim at his feet. Nearby was an open tub of Clover butter. “I ate his brain with butter. It was really nice,” Bryan, 35, told police. Later he was to tell officers: “I would have done someone else if you hadn’t come along. I wanted their souls. I used the Stanley knife to cut them off (his victim’s limbs) and some other kitchen knives but I had to stamp on them to break the bones.” Neighbours said that one officer sprinted out of the kitchen of the flat in Walthamstow, East London, and retched in the garden. He gasped to a colleague: “It’s horrible in there.” Bryan subsequently told a doctor that he also ate strips of his victim’s arm and a leg, “which tasted like chicken”. He admitted that as he attacked Brian Cherry, his victim, he had fantasised about having sex with him while he was alive and again after he was dead. These insights into the warped mind of Peter Bryan became public yesterday as the triple killer sat impassively in the dock at the Old Bailey. The short, squat man with a balding head was dressed in a black suit and blue tie. Four mental health workers and a dock officer were at his side.
Bryan, from Forest Gate, East London, pleaded guilty to the manslaughter on the grounds of diminished responsibility of Mr Cherry, 47, and of Richard Loudwell, 50, whom he killed four months after attacking Mr Cherry while on remand in Broadmoor secure hospital. The court heard yesterday that there had been a history of mental illness in Bryan’s family. At the time he was first admitted to Broadmoor after killing Mr Cherry, his brother was also a patient there. Aftab Jafferjee, for the prosecution, said that Bryan had killed three people between 1993 and 2004, and had “literally developed an appetite for killing”.
His first victim was Nisha Sheth, 20, a student whom Bryan killed in a vicious claw-hammer attack in March 1993. He struck her several times on the head and continued to do so even after she lay dead. Bryan had been working at her father’s clothes shop in the Kings Road, Chelsea, and later claimed that she had wanted to die. He was sectioned under the Mental Health Act and sent to Rampton secure hospital. He was granted a conditional discharge in January 2002 and sent to a hostel where residents have their own front door and room key and could “come in and out as they wish”. After an allegation of an indecent assault on a 16-year-old girl, Bryan was sent back to hospital. But this time he was only an informal patient on an open ward at Newham General Hospital in East London. Just hours after being granted as much leave as he wanted, Bryan walked out and killed Mr Cherry, 45, whom he had met through a friend, who had known a friend of the victim. He initially claimed that the attack on Mr Cherry started out as a botched burglary. But during interviews with psychiatrists in Broadmoor, he said that eating body parts was part of a voodoo ritual he carried out to transfer the power of his victims to himself. He described the feeling as the “quickening”. Bryan also said that he had thought about killing his father because he was old and vulnerable. As that would leave his mother alone, he decided that he would have to kill both or neither.
One psychiatrist, a Dr Lock, who interviewed Bryan, concluded that he was “probably the most dangerous man he had ever assessed”. Mr Jafferjee told the court: “In the course of (one) interview the subject of the film The Silence of the Lambs was raised. The defendant said that that was not his style, in that he (Bryan) did not plan it. ‘It just happened’.” Bryan believed that human flesh was part of the “natural food chain” and described wanting to drink human blood as it was “full of protein”. Describing the attack on Mr Cherry, he said that the more he cut up the body, the more relaxed he felt.
Although he was considered a high risk to others when transferred to Broadmoor from Belmarsh prison, where he had been held after killing Mr Cherry, Bryan was kept in seclusion for just three days. After that he was put in a medium-secure room. On the day he killed Loudwell, Bryan was described as “happy, cheerful and laughing”. But later that evening he attempted to strangle Loudwell with a pyjama cord and then banged his head violently against the floor. Loudwell, from Gillingham, Kent, had pleaded guilty to killing an 82-year-old woman in her home and had been sent to the mental hospital to have his condition assessed. After the killing Bryan said that he had been thinking of killing Loudwell for some days and had wanted to eat him. He described him as the “oldest and weakest on the ward” and the “lowest on the food chain”.
David Etherington, QC, for the defence, said: “This defendant is the victim of a terrible illness and regrettably, we must submit, he is also the victim of a State unable to control it.” He said that Bryan should not have been in a position to carry out the killings. “We suggest he was let down,” he said. “He should have been kept in conditions of the highest security.”
Sentencing Bryan to two whole life terms, Judge Giles Forrester said that life would mean life and that he would never be released. He said: “Although substantially impaired, you do of course bear criminal responsibility. The seriousness of the offences is exceptionally high, even having regard to your illness.”

How he was freed to kill
4th October 1969 - Born
18th March 1993 - Kills Nisha Sheth, 20, in Chelsea
March 1994 - Pleads guilty to manslaughter on grounds of diminished responsibility. Admitted to Rampton hospital
January 2002 - Mental Health Review Tribunal agrees to conditional discharge
August 2002 - Staff at Riverside Hostel in North London, where he is living, concerned about relationship with girl, 16
February 2004 - Accused of indecently assaulting girl. Transferred to Newham General Hospital and told he cannot leave
17th February 2004 - Social worker describes him as “happy and OK”. By 7pm he has killed Brian Cherry
March 2004 - “Extremely dangerous,” psychiatrist says after prison assault
April 2004 - Kills Richard Loudwell in Broadmoor


Bloody Blunder, Daily Mail, 17th March 2005
A string of errors that allowed cannibal killer Peter Bryan to roam free are to be investigated by three separate inquiries. One will want to know why nurses at Broadmoor hospital cleaned up the blood-stained monster after he had attacked patient Richard Loudwell. Bryan calmly told staff, who also put his bloody clothes in the laundry: "I have harmed myself." A nurse revealed: "He was extremely persuasive." Loudwell, 60, was found later, with a pyjama cord around his neck and serious head injuries. He died two months later.
Bryan, 35, was initially sent to Rampton secure hospital, Notts, in 1994 after he killed shop girl Nisha Sheth, 20. Seven years later he was transferred to a less secure unit in North London where he could come and go as he pleased. He was then moved to an open psychiatric ward in East London. During day leave he killed pal Brian Cherry, 47, who lived close by, sawed off his arms and left leg and fried and ate part of his brain. Bryan was sent to Broadmoor hospital, with a recommendation he be locked up in the most secure part. But he was put in medium security where he throttled killer Loudwell.
The first inquiry will examine the "care and treatment" of Loudwell until his admission to Broadmoor.
Another will concentrate on the treatment of Bryan and his contact with mental health experts before the killing of Mr Cherry.
The third will look at how Loudwell and Bryan came to be admitted to Broadmoor and their treatment there. The first report is expected within six months. A Broadmoor spokeswoman said: "We'll be looking very closely at what went wrong and make recommendations. We cannot comment further until the inquiry reports are published."
The three-part investigation is one of the biggest-ever into mental health services and will cost tens of thousands of pounds. An executive summary will be published once all three inquiries have reached their final conclusions.


Cannibal's social worker named, The Times, 17th March 2005
A social worker whose assessment of Peter Bryan helped to secure the release of the cannibal killer to strike twice again can be named today. Roland Silcott was convinced that the schizophrenic posed no further threat to the public and asked Home Office and mental health experts to free him. Mr Silcott, Bryan’s key social worker for 18 months, is employed by the East London and The City Mental Health NHS Trust, which declined to comment yesterday. It confirmed, though, that no disciplinary action is contemplated against Mr Silcott, who remains employed by the trust. Hours after Bryan, 35, was given as much leave as he wanted from the Newham Centre for Mental Health, he killed his friend Brian Cherry, 45, in February 2004 before cooking his brain in butter and eating it. Mr Silcott had written several letters to the Home Office saying that Bryan had recovered and was no longer a danger. The triple killer was undergoing assessment at Broadmoor secure mental hospital yesterday as demands for a full independent inquiry grew. Bryan, from Forest Gate, East London, pleaded guilty to manslaughter on the ground of diminished responsibility. Sentencing him to two life sentences, Judge Giles Forrester told him he would never be released because he was too dangerous.
Three local health inquiry panels will report within the next 18 months on aspects of the case, the East London and The City Mental Health NHS Trust said.
This was dismissed as inadequate by Marjorie Wallace, the chief executive of the mental health charity SANE. Ms Wallace said the case showed that psychiatric services were being forced to take unacceptable risks with people’s lives. “There has been a trend in these so-called independent inquiries in order to avoid the culture of blame, not to make people accountable and to make very general observations,” she said. “We should like to see a full, independent inquiry to investigate all the circumstances into the care and treatment of this man.”
A three-member mental health tribunal, which met in secret, agreed in January 2002 to release Bryan from Rampton. The decision was against Home Office advice. The Department of Health refuses to name the High Court judge, consultant psychiatrist and social work manager who made the decision.
Michael Howlett, director of the Zito Trust mental health charity, called for an independent inquiry. He said the case showed that mental health services were struggling to cope with dangerous patients. Professor Louis Appleby, the National Director for Mental Health, denied yesterday that the case indicated problems with the system. He said he would ensure that all lessons were learnt and fed into the draft Mental Health Bill. The Government could amend the forthcoming Bill. It is considering whether the legislation needs to give greater emphasis to protecting the public, rather than the rights of individual patients. John Reid, the Health Secretary, and Charles Clarke, the Home Secretary, discussed the issue yesterday. The Bill is going through the parliamentary legislative process and is due to be implemented in 2007.


Cannibal's life sentence 'no consolation to us', The Telegraph, 20th March 2005
The father of the first victim of Peter Bryan, the paranoid schizophrenic who murdered a man and ate his brain before killing a third person, spoke yesterday of his anger at the legal and mental health authorities for allowing the killer to be released. Mahendra Sheth, whose 20-year-old daughter, Nisha, was beaten to death by Bryan in 1993, said that he felt "numbed by resentment" towards the legal system. Bryan was made the subject of an indefinite hospital order under the Mental Health Act for the killing, but was deemed to have improved enough to be discharged after eight years.
In February last year, Bryan, 36, went to the flat of a friend, Brian Cherry, 43, and killed him with a claw hammer, dismembered him and ate part of his brain. Two months later, while at Broadmoor, he beat and strangled Richard Loudwell, 60, a fellow inmate who was also on remand for murder. Bryan said that if he had not been interrupted, he would have eaten Loudwell. A doctor at Broadmoor later described Bryan as "the most dangerous patient I have ever seen". Bryan was sentenced last week to life imprisonment for the killings.
Mr Sheth, 60, from Harrow, north London, said that it had been obvious since 1993 that Bryan should have been locked up for good after killing his daughter. "His life sentences now are no consolation for myself and my family and the pain we have been through," said Mr Sheth, who last week marked the 12th anniversary of his daughter's death. Bryan had worked at the Sheth family's clothing business in Chelsea, south-west London, but was dismissed by Mr Sheth for harassing his daughter. Bryan returned to the shop on the Kings Road, and beat Miss Sheth to death with a claw hammer. He also seriously injured her 12-year-old brother, Bobby, as he tried to defend his sister. Bryan later threw himself from his flat in Battersea but survived with broken legs. He pleaded guilty to manslaughter and was sent to the high-security Rampton Hospital in Nottinghamshire, under the Mental Health Act. "Nisha was our angel but we lost her in the most appalling way," said Mr Sheth. "After her death, we were told that Mr Bryan would be behind bars indefinitely, but he was released after less than eight years. How could the authorities even think about releasing such a mad killer?"
Mr Sheth said that the authorities had been too lenient with Bryan in the past. "Until an 'indefinite' sentence really means what it says, people like Mr Bryan will be free to wander the streets and kill innocent victims," he said.
Sentencing Bryan last week Judge Giles Forrester said he would remain in custody for the rest of his natural life.
But Mr Sheth said he doubted that Bryan's two life sentences would keep him in prison for good. "He will fool the authorities into believing that he is sane, just like he did after killing my daughter." Bryan was released from Rampton in 2002 after applying to a mental health tribunal, but was later admitted to the Newham Centre for Mental Health in east London. He was kept there as an informal patient and was free to leave the hospital whenever he wished. During his treatment at Newham, Roland Silcott, Bryan's social worker for the 18 months leading up to the killings of Mr Cherry and Mr Loudwell, told government officials that he should be released from the centre.
In a letter to the Home Office, Mr Silcott said that Bryan had made a full recovery and posed no further threat to the public.
The East London and City Mental Health Trust, which was responsible for Bryan's care, has set up an independent inquiry into why he was allowed back into the community. Mental health campaigners have also called for an overhaul of the care system. Michael Howlett, the director of the Zito Trust, an independent mental health watchdog, said that Bryan's case was one of the most serious breakdowns of care to occur in Britain. "It is an appalling case and is another example of somebody who has been into a high-security hospital, is discharged with conditions and has gone on to kill," he said. "The mental health services have consistently failed to prevent homicides and serious attacks by people who are already known to have a history of violence."


When will they ever learn?, The Telegraph, 20th March 2005
'Cannibal killer' Peter Bryan was deemed safe just hours before he struck for the second time. The psychiatric services have had similar cases in recent years, yet still they make the same mistakes. 'No one in mental health is complacent," insists Professor Louis Appleby, who is national director for the NHS's Mental Health services. "We want to learn the lessons of this case." One lesson that has evidently not so far been learned by those working in mental health is this: it is not a very good idea to free someone "into the community" who has a known predisposition to homicidal violence and who has killed before.
Peter Bryan, who was sentenced last week to life imprisonment for two murders he committed while under the care of psychiatrists and mental health workers, illustrates it with horrifying clarity. Bryan was allowed sufficient freedom by psychiatrists, social workers and the Home Office to kill not just once more but twice more. Bryan first came to the attention of the psychiatrist service in 1993, after he walked into a shop in Chelsea and attacked 20-year-old Nisha Sheth with a claw hammer. Bryan battered the shop assistant so violently that she died. He was diagnosed with schizophrenia and ordered to be detained indefinitely. By 2002, a Mental Health Review Tribunal had decided he was safe to be released from hospital. He was moved to a hostel in north London from which he could come and go as he pleased. Over the next year, he threatened staff and other residents at the hostel. Nonetheless, his social worker wrote to the Home Office that he was making "good progress" and "does not present any major risks". On the morning of February 17, 2004, there was an hour-long meeting to review Bryan's condition. He was described as "calm and jovial" and there were "no concerns regarding his mental state".
Later that same day Bryan went out and bought a claw hammer and a screwdriver from a hardware store. He then went to visit his friend Brian Cherry. He battered Mr Cherry to death with the hammer, sawed off both his arms and left leg, scooped Mr Cherry's brains from his skull and proceeded to fry them in butter before eating them
Bryan was arrested, covered in blood, when police, alerted by neighbours, visited the flat. The police doctor who examined Peter Bryan said his mental condition "did not necessitate an urgent transfer to hospital". He was remanded to Belmarsh Prison, where he assaulted staff and behaved "unpredictably".
He was diagnosed as mentally ill and sent to Broadmoor on April 15, 2004. After only three days, he was placed in a medium-security ward, where he was left alone with other patients. Within a week, he had murdered one of them: Richard Lourdwell. When asked why he had done it, Bryan said: "I wanted to kill and eat him. Cannibalism is natural… If I was on the street, I'd go for someone bigger for a challenge."
An inquiry into the circumstances that led to Bryan's two most recent homicides has been announced. Prof Appleby's insistence that psychiatrists "are not complacent" might be understandable if the kind of blunders that led to Bryan being released into the community were unprecedented.
Unfortunately, they are not - as is shown by the inquiries that have been held into the many previous killings by mentally ill patients who had been convicted of assault and even murder, yet were still released "into the community".

More than a decade ago, Jonathan Zito was stabbed to death by Christopher -Clunis while waiting for a train at Finsbury Park. The report into the events that led up to that murder revealed that Clunis had been under the care of psychiatrists for more than 10 years. He had stabbed at least two people, and attacked several others, before he killed Mr Zito. The inquiry found, however, that "time and again violent incidents were either minimised or omitted from records, or referred to in the most general of terms in discharge summaries". The inquiry discovered that Clunis had been seen by 43 different psychiatrists in four years. Not one of them had had a full and accurate copy of Clunis's medical and criminal records. They were taking decisions about whether he was safe to remain "in the community" on the basis of inaccurate information.
The report into Clunis identified a string of additional failures by the mental health professionals involved in his care. These included: a failure to "achieve proper communication and liaison"; a failure to "assess Clunis's past history of violence and … his propensity for violence"; a failure to "manage provision of health and social services"; and "a failure to note and act upon warning signs and symptoms to prevent a relapse" when a patient is living in the community. But, the report said, no one was to blame.
The reaction of the psychiatric profession to the Clunis Report was very like Prof Appleby's reaction to Peter Bryan last week: it was to insist that "we are not complacent" and "we will learn the lessons". The lessons, however, have not been learned. That is clear from the reports published in the decade since the Clunis Report: they have each identified the same failings in the system - failings that are then found to have been repeated all over again when the next report is published into the next killing by a mentally ill man with a history of violence who has been released "into the community".

Take, for example, the case of Winston Williams. Williams was a diagnosed schizophrenic who was known to aggravate his condition by habitual drug use. He was sent to Broadmoor in 1979 for stabbing two people in London and for telling a 13-year-old boy that he was going to kill him. Twelve years later, Williams was thought safe to release. He had to be readmitted to secure care because he threatened to kill his social worker and refused to take the medication that controlled his symptoms. He was, however, soon thought to be safe to release again. The results were fatal for Katie Kasmi, a 25-year-old woman whom Williams stabbed 77 times on February 19, 1999. What did the inquiry into Williams's care find? Almost identical failings to those identified in the Clunis report. His file did not contain a complete set of his records. His record of violence was minimised and he came to be treated as "a minimal risk and socially stable", rather than the violent, substance-abusing man that he was. There was a failure of communication and liaison between the agencies. There was a failure to monitor his care "in the community". But, the report said, no one was to blame.

The Williams Report, which was published in 2002, had followed hard on the heels of the report into Richard Gray, which was published in 2001. Gray strangled Virginia Sivil while she was in the first stages of labour with their third child (the child died as well). Gray had previous convictions for rape and drug abuse. He had been admitted to, and discharged from, psychiatric hospitals 13 times before he killed Ms Sivil. In the four months before the killing, Gray had repeatedly told his community psychiatric nurse that he wanted to kill Ms Sivil, their two children and his parents. The psychiatric nurse, however, did not inform Ms Sivil, nor her parents, nor any psychiatrist or mental health worker about those threats. The report identified the usual errors: a failure to keep accurate records; a failure of communication between different agencies; a tendency to minimise Gray's violent past; a failure to monitor him carefully "in the community". But, it said, no one was to blame.

Then there is the report, published four months ago, into Paul Khan, who killed 72-year-old Brian Dodd in an unprovoked attack in 2003. Khan had been diagnosed as a paranoid schizophrenic and he was a known drug user. He had a history of violence: he had carried out a vicious and violent knife attack in 1996, for which he had been admitted to Ashworth Maximum Security Hospital in Merseyside. In 2000, however, he was deemed suitable by a Mental Health Tribunal for "independent living in the community". When he went off to stab Mr Dodd to death, Khan's care workers - who were supposed to ascertain his whereabouts every 12 hours - either didn't notice or didn't care: it was left up to his parents to report him missing. Guess what the report into Khan's killing of Brian Dodd found? Correct: there had been a failure to keep accurate records; a failure to monitor him after he was released in to the community; a failure to monitor his drug abuse; and a failure of co-ordination between the various agencies responsible for him. But no one was to blame.

We can expect the same litany to be repeated when there is report into John Barrett's killing of Denis Finnegan, which took place in September 2004. Barrett, who will be sentenced for that killing next Tuesday, had a history of violence. He had spent 18 months in a secure unit after stabbing two patients and a nurse at an out-patient clinic. He was released, but his girlfriend noticed that his condition was deteriorating and alerted his psychiatrist. He was assessed, and deemed safe to be allowed to walk away unescorted. He then left Springfield Hospital in south London, bought a set of knives from a DIY shop and went to Richmond Park, where he stabbed Mr Finnegan to death. We can be sure that the report won't blame anyone for that either.

These are by no means all of the instances of killings by men known to be insane, and to have a record of violence, but who have been deemed "safe to live in the community" - or of the reports into how the decisions to release them were made. (There have been at least six such reports in the past 10 years.)

Psychiatrists often claim that they are not to blame because their patient's "violence could not be predicted". Professor Paul Mullen, an Australian psychiatrist, says that is just wrong: it often can be predicted. "There are some very strong, and very obvious indicators: if the patient is male, has a history of previous violent attacks, doesn't take his medication, and abuses drugs, then it is pretty likely that he will do something violent again." Those are precisely the indicators that have often been missed or ignored in recent cases where mentally ill people have been released "into the community" only to kill someone. The consistent failure of the psychiatric profession to absorb the lessons of the failures documented over and over again in the official reports makes it hard to believe that those lessons ever will be learned.

Perhaps the truth is that they do not want to learn those lessons. "Every system for assessing people will involve mistakes," explains Dr Anthony Daniels, a psychiatrist who has worked in prisons and frequently assesses the threat a mentally ill individual poses. "There is only one way to prevent released mental patients with a previous history of violence from killing people and that is to have a rule that says if you are mentally ill and you murder someone, or seriously assault them, you will not ever be released. That rule would inevitably be very harsh, indeed cruel, to the many mentally ill people who have committed homicide or very serious assault once, but would not do so again, because their condition is controlled. But it would ensure that a man such as Peter Bryan could not kill more than once."

Many psychiatrists who defend the present policy of releasing patients with a history of violence back into the community seem to do so on the basis that the deaths they cause are an acceptable price for not detaining mentally ill people in secure institutions. It is better, in their minds, that some people should be murdered occasionally, than that hundreds of mentally ill patients be permanently locked up. An open, public debate on that issue urgently needs to be held. But until it is honestly recognised that those are the options, and until we stop pretending that the present system can be improved to the point where the lessons are learned and dangerous patients are not released "into the community" to kill, it will be impossible to have that debate. Which means that we can expect fresh killings, fresh reports which identify the same old failings - and more psychiatrists repeating over the airwaves that "We are not complacent … we want to learn the lessons."






Inquiry after schizophrenic dies of heart attack, Leigh Today, 18th March 2005
Staff at Leigh Infirmary psychiatric unit tried in vain to revive a 41-year-old patient when he had a heart attack while they were attempting to restrain him. Health chiefs have launched a probe into the tragedy which happened at the hospital on Saturday and have been in contact with the patient's family. But the family of Mark Warriner of Stockbridge Village, say they have a lot of questions needing answers. His mum, Mrs June Warriner said: "The first we heard was on Sunday when we got a phone call to say Mark had suffered a heart attack, and I just couldn't believe it because he was as strong as an ox and had no history of a heart complaint." Mr Warriner, who had a history of schizophrenia, had admitted himself to the hospital voluntarily, but then became animated and anxious and it was felt he needed to be restrained either for his or other people's protection. A spokesman from the Five Boroughs Partnership NHS Trust, which handles psychiatric services at Leigh Infirmary, said: "Events such as this are very rare within our services and we are naturally upset by this incident. We are offering all the support we can to the family members and our staff. Our staff reacted rapidly and appropriately, providing immediate medical attention." The coroner has been informed and the death will eventually be the subject of an inquest. Mrs Warriner, added: "We can't believe what has happened and are in shock. We don't know what has gone on, and there are a lot of questions we want answered. Mark was a big softy and was never aggressive. He enjoyed swimming and loved his clothes. He used to organise trips for other mentally ill people." Mark had been well for four years, but the week before he died, he was feeling depressed. He was under the care of Whiston Hospital, but was sent to Leigh Infirmary on Sunday, March 6, because Whiston could not take him.



Danger patient pleaded for help, Sheffield Today, 24th March 2005
A Sheffield grandmother died in an arson blaze because a paranoid schizophrenic did not receive the correct treatment. Abdirisak Hussein started a blaze which killed Amina Ali just hours after pleading for help from a social worker in the street. Sheffield Crown Court was told Hussein had not received any psychiatric supervision for six months before the death, despite making public death threats. The court was also told if Hussein had been given the correct anti-psychotic medication he would not have killed. Somali refugee Hussein killed Mrs Ali last February in a deliberate blaze at her Sharrow home on Mount Street. The brave Somali woman, aged 56, died from smoke inhalation in the council flat inferno after throwing two of her grandchildren 50 feet to safety. Her grandson was caught by passing pedestrian Ndeka Lufuluabo but his six-year-old sister fell to the ground, suffering horrific head injuries. She has since made a full recovery, and Mrs Ali's husband Mijir Mohamoud survived by climbing out of a window and clinging to a ledge.
Mr Justice Andrew Smith said: "The terrible nature of this offence can hardly be stated. Amina Ali put the lives of her grandchildren first, and mercifully she saved them." Hussein, who lived "just a stone's throw" from his victims on Cliff Street, Sharrow, denied murder but pleaded guilty to manslaughter on the grounds of diminished responsibility. He also admitted arson with intent and was sentenced to indefinite detention in a hospital under the Mental Health Act. Jeremy Baker QC, defending, said: "His mental illness was entirely treatable to the extent he would have been safe in the community if he had taken the correct medication."
Jeremy Richardson QC, prosecuting, said Hussein was suffering from "dangerous paranoid delusions" following his release into the community from a psychiatric facility. The 37-year-old, who is a member of the Somali tribe, had become fixated with Mr Mohamoud and had repeatedly threatened to kill him. On occasions he had spat in his face, claiming he was gay and a member of the Ethiopian secret service. The court heard that a social worker had become so worried about his behaviour he expressed concern to his colleagues. Hussein was obsessed with Mr Mohamoud, aged 61, because he was a member of the Black Adam Tribe, an African clan that Hussein hated.
Witnesses saw Hussein throw a chair at him in Sunnybank Community Centre in Broomhall and say: "I am going to kill a member of the Black Adam Tribe."
On the day he torched the maisonette, Hussein was seen wandering around Sharrow with a plastic petrol container.
The court heard at one point he approached Joseph Jones, a team manager for Sheffield Council Social Services, outside Hanover Medical Centre. Mr Richardson told the court: "He asked for help and was reassured that he would get some." But already earlier that day, Hussein had poured petrol into Amina Ali's hallway. A relative called the police who advised them to contact South Yorkshire Fire Service, and 56-year-old Amina Ali simply cleared up the mess. Within hours, Hussein returned, poured more petrol through the door and lit a match.
Kevan Taylor, Chief Executive of Sheffield Care Trust, and Cath Roff, Sheffield City Council's Acting Executive Director of Social Services, said in a joint statement: "This was a very tragic incident and our thoughts and sympathy remain with the family and friends of Amina Ali. Mr Hussein did have contact with our services over a period of time including between June 2003 and February 2004. Sheffield Care Trust and other agencies involved have looked carefully at the processes involved so that any appropriate action can be taken."








Prison 'let down' suicide inmate, BBC News, 2nd March 2005
A vulnerable inmate who committed suicide behind bars was let down by the Prison Service, a jury has ruled. After a five-week inquest, jurors found a series of failures contributed to the death of police informant Paul Day. The 31-year-old from Southend on Sea, Essex, was found hanged in HMP Frankland, Durham, in October 2002. The hearing at Chester-le-Street magistrates heard the convicted robber was bullied by other prisoners but staff failed to do enough to stop it. The Coroner Andrew Tweddle said he would be passing the inquest's findings on to the prison authorities. The Governor of Frankland Phil Copple expressed his condolences to the family and said an internal investigation had highlighted "procedural shortcomings" which had been addressed.
The hearing heard how Mr Day, who was serving an eight-year sentence, was supposed to be closely observed because it was known he wanted to harm himself. Before being moved to Frankland Prison he had been at Wandsworth Prison and on one occasion prison officers had urged him to jump from a high gantry, the inquest heard. The hearing also heard how Mr Day had told a prison chaplain he worked on robberies with corrupt Flying Squad officers and was targeted for abuse from fellow inmates. He protested about his treatment and was sent 300 miles from his native South East to Frankland which he thought was a witness protection unit. The jury found he had been misled and decided he had committed suicide. The inquest jury foreman said: "We believe the effect on Paul was that he felt abandoned, frustrated, depressed, helpless and defeated. He also lost any trust in the system and in his carers."



Suicide driver escapes jail term, BBC News, 8th March 2005
A man who tried to commit suicide by driving head on into a van after being kept awake by fireworks the night before has escaped a jail sentence. John Babbage, 61, drove his Nissan Micra into Andrew Petchey's Citroen van on the A37 near Yeovil, Somerset, in November 2004. Mr Babbage, from Yeovil, was given a nine-month suspended sentence at Taunton Crown Court. He was also banned from driving for a year by the court. Passing sentence, Judge Stephen O'Malley, said: "This is obviously a sad case. You attempted to take your own life in a way that endangered the lives of others. Your driving was dangerous and intentionally so. It was merciful that no one was injured. You deliberately created a dangerous situation where injuries could have happened."
Lawrence Wilcox, prosecuting, said on the day of the accident Mr Babbage's car drifted in the path of Mr Petchey's van. "Mr Babbage's vehicle hit the rear side of the van which swerved into oncoming traffic." Mr Petchey suffered slight injuries in the crash. Afterwards, Mr Babbage told the paramedics: "I tried to find the biggest vehicle I could drive into so I could commit suicide." Alan Large defending, said: "It was merciful that the driver of the other vehicle was not hurt. The consequences could have been catastrophic. Mr Babbage realises it was an awful thing to do." Mr Babbage's sentence was suspended over a two year period.



Suicide GP was 'under pressure', BBC News, 10th March 2005
A village doctor killed himself after being put under pressure to cut the number of patients he referred to hospital, an inquest has heard. Dr Stephen Farley, of Ibstock House Surgery, Ibstock, Leics, was found hanged in January 2004. Charnwood and North West Leics Primary Care Trust investigated Dr Farley, 55, for sending too many of his patients to see hospital specialists. North Leics coroner Trevor Kirkman recorded a verdict of suicide. "This death clearly should not have happened," Mr Kirkman said. The inquest at Loughborough Magistrates Court on Thursday heard that Dr Farley had found the investigation "extremely stressful", causing him to take time off work and see a psychiatrist. In a statement read out in court, the GP's widow, Marion Farley, said her husband had been referring more patients to hospital than other doctors because he was very popular. She said: "My husband was contacted by health authority bosses and questions were asked of my husband of the number of referrals, but this was because patients would wait and wait to see him." Concerns were first raised with Dr Farley over the frequency of hospital referrals in 2000. Letters were sent to Dr Farley requesting that he be retrained. An earlier independent health panel said Dr Farley "took on a very challenging workload, motivated by his desire to serve the local community". But that investigation ruled the Charnwood and North Leicestershire Primary Care Trust had been right to raise questions about the number of his hospital referrals.



Suicide risk 'lowest since 1973', BBC News, 10th March 2005
Adult suicide rates are the lowest they have been for 30 years, according to new government figures. The Office for National Statistics said there were 5,755 suicides in the UK in 2003, the lowest number since 1973. The highest rates were in the North West and North East of England and in Wales, with the highest rate for men being in Blackpool, Lancashire. The highest rate for women was recorded in the North West and the lowest in the East of England. The rate in Blackpool between 2000 and 2003 was more than twice the national average, with 39.1 deaths recorded per 100,000 population. Blackpool has also been identified as having the highest teenage pregnancy rate, and the highest number of alcohol-related deaths among men. For women, the highest individual rates were in Camden, London, and in Conwy, north Wales, at 13.8 and 13.6 deaths per 100,000 population respectively. Suicide rates for men rose steadily throughout the 1970s and 1980s, but the rates have dropped since 1998.
The national director for mental health, Professor Louis Appleby, said: "Today's figures are welcome confirmation of the improvements that we know are happening nationally to reduce suicide rates. Young male suicides remain our biggest challenge, though they are beginning to show signs of reduction. The National Suicide Prevention Strategy highlights young male suicides as one of its priorities and we will continue to work towards reducing the number of suicides further."
Health Minister Rosie Winterton welcomed the figures. "I'm extremely encouraged by these figures," she said. "The sustained downward trend shows that our National Suicide Prevention Strategy is having an effect."
Marjorie Wallace, Chief Executive of the mental health charity SANE, said: "We welcome the reduction in the overall number of adult suicides shown in these figures. However, the rate is still unacceptably high, especially amongst young men and mentally ill people in prison. There is also disturbing evidence, shown in research carried out by SANE and others, that the numbers of those who self-harm is growing, and that they are doing so in increasingly damaging ways."

Press release
http://www.statistics.gov.uk/pdfdir/suicide0305.pdf

Full report (Excel)
http://www.statistics.gov.uk/downloads/theme_health/Suicides_2000_2003.xls



Second worst female suicide spot in Britain, Daily Post, 11th March 2005
More women commit suicide in Conwy than anywhere else in the UK other than Camden in London, figures revealed yesterday. The county has more than twice the British average for suicides among women aged 15 and over. In 2003 Conwy saw 13.6 deaths per 100,000 population, compared with the UK average for women of 5.8 per 100,000. The combined rate of suicides among men and women in Conwy was 19.3 per 100,000, the fifth highest in the UK. Ruth Coombs, policy manager for MIND Cymru, said preventing suicide should be a key focus in mental health service standards. In England, there is a national suicide strategy, while in Wales guidelines are part of the NHS framework. She said: "We would want the Assembly government to implement the key actions within the national service framework for suicide and we would look for evidence these key actions are being implemented." A Welsh Assembly government spokeswoman said yesterday: "Suicide prevention is a priority for services. It should be addressed by delivering high quality and responsive evidence based care using relevant NICE guidelines and the recommendations of the national confidential inquiry into homicide and suicides, Safety First. England and Wales does have one of the lowest suicide rates in the world and we will continue to work at reducing this through our national service framework and through implementing strategies promoting social inclusion. We are also working closely in partnership with the national public health service to look at how this issue can be taken forward in Wales."



Coroner-based investigation of specific methods of suicide, National Institute of Mental Health in England, 18th March 2005
Reducing availability and lethality of methods of suicide is a key goal in the National Suicide Prevention Strategy for England (2002). In order to determine how this might best be effected, and also how the danger of specific methods might be reduced, including through improved treatment following suicidal acts, it is necessary to have detailed information on suicides in which these methods have been used. This study was established in order to achieve this aim in relation to certain specific methods of suicide, namely:
Hanging
Firearms
Co-proxamol poisoning
Self-poisoning in which the individual reached hospital alive

The study was conducted by examining coroners’ records of suicides in which these methods were used. Eight coroners’ jurisdictions within reasonable travelling distance of each of the three research centres were randomly selected (i.e. 24 in all). The cases included in the study were those receiving a coroner’s verdict of suicide, or an open verdict in which the research team judged there to have been a high or moderate probability of suicide.

Structured data-extraction forms were used to record the following broad areas of information (detailed items were used within each area): demographic characteristics of the deceased, circumstances of the act (method, timing, location, discovery), toxicology (alcohol and blood levels), contact with psychiatric services and general practitioner, and previous self-harm. Part of the Beck Suicide Intent Scale, based on the objective circumstances of the act, was also completed. More detailed information on each specific method under investigation was recorded on additional sections of the forms. For each case a brief vignette was compiled, including any other relevant details from the inquest records. In addition, for each method of suicide, selective literature reviews were conducted to provide both background information for the empirical studies and to supplement the conclusions.
A further aim of the study was to determine the extent to which coroners’ records are a satisfactory source of information for studies of this kind. The study was conducted through a collaboration involving centres in Oxford (Keith Hawton, Lesley Sutton, Sue Simkin, Camilla Haw), Bristol (David Gunnell and Olive Bennewith) and Manchester (Navneet Kapur and Pauline Turnbull). It was co-ordinated by the Centre for Suicide Research in Oxford.

Executive Summary
http://www.imhl.com/members/word_docs/Coroners.doc



Hospital withheld patients' food, BBC News, 21st March 2005
A coroner has ruled food and drink was deliberately withdrawn from patients at a Derby hospital in the 1990s. But the inquest into the deaths of 11 elderly men at the Kingsway Hospital ruled that all died of natural causes. Deputy Coroner Sir Richard Rougier said there had been "an unhappy atmosphere" in the ward where the men died. But he added there were too many uncertainties to say the policy of withholding food - for fear of choking - contributed to their deaths. Mr Rougier, however, criticised the management in his ruling and said doctors had left decisions about the treatment of patients to nursing staff. The inquest heard all 11 were in the terminal stages of senile dementia and died from bronchial pneumonia between 1995 and 1997. The inquest at Derby's Pride Park heard it was common for severe dementia patients not to be given food and drink.
Chris Gawne, a solicitor for some of the families in the case, said after the verdict: "The families are relieved that the inquests have now come to a conclusion and are confident that the causes of these patient's deaths have been properly and rigorously examined. The families can take comfort in the fact that their loved ones died solely
because they reached the end of their natural lives."
A consultant psychiatrist had told the inquest earlier that not feeding patients could be in their "best interests". Dr Maureen Royston said many patients with dementia suffered eating difficulties or a lack of interest in food, which can lead to choking or pneumonia. "I have been involved in that scenario where it became quite clear that a patient cannot swallow anything safely and the best interests of that patient would be not to continue and not to put them through what must be an unpleasant experience," she told the inquest. A police investigation launched in 1997 led to the suspension of three hospital workers but no-one was charged. Sir Richard Rougier, a retired High Court judge, was appointed as a deputy coroner to handle the case as it was expected to last several months. A witness said staff had drawn up a so-called "death list" of patients they thought had died before they should have, the inquest heard. The 18-bed ward for elderly male patients suffering long-term illness closed in 2001.



Coroner criticises mental unit after patient is found hanged, icSouthLondon, 25th March 2005
A Coroner has criticised staff at a mental unit after a patient was found hanged. Dr Roy Palmer said nurses should have shown a greater sense of urgency when they discovered they could not get into patient Mark Viccary's room at the Selhurst Hostel, in Selhurst Road, South Norwood. He also queried why it was left to the following day before the door of his top-floor room was forced open. The inquest at Croydon last Thursday heard that Mr Viccary, 30, was found hanging inside. An open verdict was recorded after the coroner ruled there was not sufficient evidence to justify a suicide finding. Mr Viccary, an unemployed software designer, of Cloister Gardens, Woodside Green, had been admitted a number of times to the Bethlem Hospital, in Beckenham, because of depression. He was transferred to Selhurst, an offshoot of the hospital, where there are nurses and carers, but no doctors. He was there as an informal patient, explained staff nurse Oliver Aidoo. A nurse told Mr Aidoo on the afternoon of July 13 that he could not get into Mr Viccary's room. The works department at Bethlem was then asked to get access, which they did the following morning. Mr Viccary was discovered dead, with a ligature around his neck, and the other end tied to the door handle. Hostel manager, Julius Oni, said he used a master key on that night, after learning that there was no response to calls made to Mr Viccary, but could not get it to operate properly. He said the lock seemed to be faulty. The coroner said staff ought to think of future changes that could be made in similar situations. Dr Palmer said: "The hostel will no doubt review their policy about getting access to rooms. There is always a balance to be struck. This is supposed to be a free country."


Excerpts reproduced with kind permission of The Institue of Mental Health Law. For further information about membership go to www.imhl.co.uk