Blood and Whitewash

EXPERIENCES IN MENTAL HEALTH CARING

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WHO IS A CARER? ARE YOU A CARER? CARING ABOUT CARERS

BLOOD AND WHITEWASH

A Critique of the Inquiry into the Release of the Camden Ripper

While attempting by sheer bulk, 245 printed pages to show how thorough an investigation had taken place, on close reading the reverse is the case, The ‘hidden complication’ of the report is that it covertly seeks to avoid attaching blame to those responsible, openly attacks those who seek to identify the guilty parties and from a logical point of view, ‘cause and effect’ does not seem to exist.

1.1.9

When someone who murders has a history of mental illness, the media commonly attribute the former to the latter, even in the absence of any clear evidence. This problem is compounded by the well-meaning but potentially misguided efforts of pressure groups seeking to use such tragedies to argue the case for better care for the mentally ill. Both reporting in the media and the action of pressure groups just described serve to reinforce the view that mental illness was responsible for the murders, and that, were it not for inadequacies in the treatment the individual received, the tragic outcomes would have been averted. Clearly, each case must be considered separately, but overall it remains true that the most murders are committed by people who do not have mental illness, and those with mental illness are much more likely to be the victims of violence than its perpetrators.

The paragraph bubbles with misinformation, nonsequiturs and plain dishonesty. The attribution of homicide to those with a diagnosis of psychotic illness is hardly the invention of the tabloid press. ‘The absence of clear evidence’ means precisely what? Precisely nothing in my opinion and how Professor Sensky seeks to justify such an assumption is incomprehensible. The comment that ‘most murders are committed by people who do not have a mental illness’ (and this applies to Anthony Hardy) raises many questions. Primarily (if this is the case) why was Hardy been remanded to Broadmoor from December 2004? The press do not seem to have picked up on this small matter buried deep in the report. The latest Home Office statistics show that 91% of all prisoners have some kind of mental illness - are murderers miraculously exempt from this figure?

Perhaps what they are saying - or inferring - is that most victims of homicide are known to their victims and have not been previously patients with a diagnosis. It is a given of psychiatry that stressors trigger mental illness and that marital breakdown, infidelity or whether causes the homicide in question is in fact a psychiatric episode. The French for centuries have had the legal defence of Crime passionelle which reflects this.

Just who are the ‘pressure groups’ seeking to use such tragedies to argue the case for better treatment of the mentally ill? Rethink, Mind, The Daily Mail, The Zito Trust. Surely not - they have their own agendas, some of which I most certainly do not share. It is surely society in general, ‘the man on the Clapham omnibus’. The DOH’s suicide prevention strategy has demonstrated just how successful ‘suicide proof wards’ can be and to infer that the extension of good practice to mental health care as a whole is wishful thinking shows how fundamentally flawed the report is. That those suffering mental illness ‘are more likely to be the victims of violence’ is not the point – it may be true but is in no way related to the release of Hardy into the community, which the report purports to investigate. The blame for Hardy’s homicides is laid at Hardy’s own door.

‘Mr Hardy alone was responsible for his actions’ is like saying that Hitler alone was responsible for the Holocaust. Hitler was allowed to murder six million Jews because of a well documented series of events: collusion, indecision, populist racism and economic instability. Hardy’s release was the result of ineptitude, management interference in clinical decisions and the lack of available evidence presented to the tribunal which agreed his last release.

The prediction of aberrant behaviour is, of course, often difficult to predict but in Hardy’s case the evidence is there, in his medical history.

1.1.11

It is clearly the responsibility of an inquiry such as this to scrutinise with the utmost care every aspect of the perpetrator’s psychiatric history in the search for answers. Our experience has been that the evidence in this particular case calls into question widely shared assumptions about the capacity of mental health professionals to predict and manage aberrant behaviour. The three assumptions we have in mind are: first, that depravity is in itself a manifestation of mental disorder and therefore properly a matter for psychiatric intervention; second, that unlike other forms of violence, violence that occurs among people with mental disorder is predictable by psychiatrists; and third that, if they are performing properly, psychiatrists, or more generally Mental Health Services, are able to prevent people who suffer from mental disorder commuting acts of violence.

The term ‘depravity’ is Victorian, indeed the whole report is Victorian in its capacity to split the mad from the bad. Psychiatric theory and practice is hardly a ‘seamless garment’ and forensic psychiatry even less so. The view that the mad are ‘depraved’ suggests long outmoded behavioural norms. By the same standards homosexual behaviour is also’ depraved.’ The report writers have not thought through

the implication of what they have stated and in fact they seem hardly to have thought at all. As Dr Leavis remarked “They do not know enough and even worse they do not know that they do not know.”

Section 1.1.12. ‘personality disorder’ is a blanket term like ‘psychosis’ or ‘neurosis.’ The World Health Organisation manual categories ten such disorders (ICDIO scale) ‘The Diagnostic and Statistical Manual’(known as DSM IV T. (R) gives 12 but the vastly more comprehensive ‘Spectrum of Borderline Disorders (Harvard University Press) categories more than 400. Its author, W. Meissner is a Jesuit priest, a psychoanalyst, the author of manifold books and articles and Professor of Psychiatry at Harvard. To suggest personality disorders are ‘untreatable’ is ridiculous – there are a huge variety of manuals (mainly American) which provide detailed protocols for diagnosis and treatment.

There exists a semantic confusion between treatment, management and cure, also assumptions about what psychiatrists agree about and what should be ‘taken on trust’ by the report’s readers, lay or professional. The report at its most simplistic attacks anyone who says Hardy should have been treated differently with hindsight. The huge defensiveness which permeates the whole project, ‘the hidden agenda, tumbles out on almost every page. ‘Psychiatry’, the ‘Criminal Justice System’ are terms which are so sweeping as to bereft of all meaning. The statement that ‘mental illness’ was not a contributory factor is in these three murders is breathtaking in its ineptitude. Do they mean – as surely they logically must, that his actions were those of a sane man?

One of Hardy’s victims has given the press a detailed description of Hardy’s mental state when he attacked and tried to kill her. She had no doubts of his insanity.

1.1.15

The third assumption draws not so much on the notion of the predictability of violence but on the fact that society invests psychiatrists, and Mental Health Services generally, with legal powers and resources which enable them to detain and treat those who are mentally disordered and potentially violent. The assumption is that treatment properly administered will reduce the risk of violence and that until the risk is sufficiently reduced the necessary legal powers of detention are available and should be used. This has a particular resonance in Mr Hardy’s case, given how soon after he was discharged from detention under the Mental Health Act he killed his second and third victims. Mr Hardy was detained because he was assessed as being mentally ill and in need of treatment for mental illness. It is not the proper role of Mental Health Services to contain people who may be violent but whose violence is not connected to the mental illness for which they are being treated. If society wishes to detain people who are thought to be potentially violent, or otherwise to manage them so as to reduce the risk that they will behave violently, this is distinct from psychiatric treatment.

‘Sectioning’ (e.g. detaining patients under the Act as a danger to themselves or others) is not perfect but is adequate a case like Hardy. By not providing the evidence to the last panel it is hardly surprising that they came to an erroneous conclusion.

No one expects perfection of the Hardy team. Just doing the job they were paid for would have been more than adequate and lives would have been saved. The final sentence (regarding the detention of dangerous psychotics) is highly implausible. Risk management and psychiatric treatment are often one and the same, certainly there is a considerable overlap. ‘Cure’ in psychiatry is an unlikely outcome, alas. ‘Furor curandi’ (frenzy to cure) is the perpetual scourge of psychiatry. Mental illness is not operable, no tests are reliable and all diagnoses subject to dissension. One of the manifold flaws of the report is that it treats psychiatry almost as a ‘hard science’ (like chemistry) and not as a ‘soft science’ (like sociology). Mr Hardy’s motivation to kill was not, absolutely not, anything but rampantly psychotic. The diagnosis of bipolar depression (mood swings plus addiction) seems doubtful in Hardy’s case. Hardy hallucinated himself as St George which suggests paranoid schizophrenia – as is the case with Peter Sutcliffe, the Yorkshire Ripper.’

Because the report is not a public inquiry but a ‘root cause inquiry’ names are not reveled.

1.1.16

In scrutinising an individual case in great detail, it is almost inevitable that shortcomings in the patient's care and treatment will be identified. When any failings in care are discovered, there is a temptation to attribute the tragic outcome to these. This assumes that with perfect care by the clinical team, and infinite resources at their disposal, the homicides would have been prevented.

1.1.18

The comparison we would make is with a case where someone’s dangerousness is linked to a disturbed mental state in the context of a treatable mental illness. In such a case there may be a causal relationship between a failure to treat the illness and the patient’s actions, such that had the illness been treated the patient would not have acted dangerously. This is not such a case. We consider that the only way to have prevented Mr Hardy from offending would have been to detain him where he would not have had access to potential victims. That is an easy proposition to formulate but it would not have been possible to justify such an approach on the basis of what was known at the time.

The palpable red herring of ‘treatable mental illness’ is raised again. The plethora of textbooks on treatment suggests otherwise. I disagree that at the time there was insufficient evidence to detain Hardy. The evidence was in the report delayed in Erville Millar’s post room according to the Channel 4 programme broadcast in 2004. I am deeply suspicious of this excuse. When patient notes were sent to me by CHMSCT they came by courier.

3. Structure of the report

1.3.1

We took the decision not to identify any of those referred to in this report, with the exception of Mr Hardy himself. Sally White, Elizabeth Valad, Bridgitte Maclennan and Professor Maden. This is because of the publicity this case has attracted and our wish to ensure that individuals are not singled out for personal criticism which could be stressful for them and potentially unfair. If it is suggested that there is a public interest in naming any of the people referred to in this report, this is a matter which in our view should be decided by those who commissioned the Inquiry.

1.3.2

The report begins with a narrative chapter, covering the period 20th January to 30th December 2002. This is based largely on medical notes and other contemporaneous records, including police statements, supplemented by the written and oral evidence to this Inquiry.

1.3.3

The ten chapters which follow (chapters 3 - 12) are thematic. In each we take a separate aspect of the case, discuss the issues raised and draw conclusions. We have placed the thematic chapters in alphabetical order, but they can be read in any order. We have tried to help the reader by including cross-references between thematic chapters and back to the narrative chapter.

1.3.4

Our recommendations, which follow from the discussion and analysis in the thematic chapters, are in chapter 13. There is then, in chapter 14, a summary of the report. It may assist readers to start with the summary, which provides a comprehensive overview, before reading the individual thematic chapters. The summary is followed by a number of appendices, including a key to the people referred to by initials in the body of the report and a glossary.

What a wonderful get-out - ‘those who commissioned to inquiry’ are hand in glove with CIMSCT, Camden Council and the London North Central Strategic Health Authority.

CHAPTER 2

Hardy poured battery acid into a neighbour’s flat. When the police searched Hardy’s flat they found the dead body of Sally White. Hardy was arrested on suspicion of her murder. Dr Y (Dr Patel) the forensic pathologist bungled the post mortem but has not been struck off and still practices. It is high time GMC was abolished and replaced as the government threatened. The balance of two doctors to one lay assessor weights GMC procedures and the failures of the GMC in the Shipman case are well documented.

Subsequently the charges against Hardy were dropped and he was transferred to PICU (Psychiatric Intensive Care Unit) and then to an acute adult ward. Dr D spoke of Hardy’s frequent alcoholic blackouts and found them inconsistent with the planning and expectation included in the criminal damage matter. Mr Hardy’s euthymia (very cheerful state) was no doubt due to his having escaped detention for Sally White’s death, but of course this is in with the benefit of hindsight!

When Hardy consistently broke the terms of his section by drinking heavily during periods of unexcused leave he should have been transferred to a strict regime hospital e.g. back to PICU or to a secure unit, instead of which his unescorted leave was increased to six hours per day.

2.4.12

He was next reviewed by Dr E at a ward round on 13th June. He said that he felt well. He was due to see Mr V at the Alcohol Advisory Service that afternoon. He said that his aim was to be able to drink small amounts of alcohol rather than complete abstinence. He requested periods of extended leave to enable him to visit his flat. Dr E increased his daily unescorted leave to six hours.

A considerable amount of space is given to Hardy’s erectile impotence and alcohol problems. Both are symptoms as much of schizophrenia as bipolar depression but no consultant seems to have considered that diagnosis.

Hardy was discharged into the community in spite of the acid battery events and lingering suspicions about the death of Sally White. There exists an unfortunate mind set in some psychiatrists that ‘care in the community’ should be the treatment goal for all. It is a dangerous mind set. There are many for whom ‘care in the community’ is simply insufficient, not because they are dangerous but because they are too ill. The present system made no provision for them, presumably because it is too expensive. These patients constantly revolve through the doors of ward, half-way house, community care, psychotic breakdown and re-admission. Chapter 2 ends with entries which speak volumes.

2.6.23

On Friday 27th December Mr Hardy went to Cardigan ward at 8.45pm to collect a week's supply of medication. He stayed for 10 minutes. He appeared mentally stable. On 30th December he attended Tottenham Mews for about three hours during which time he made a number of telephone calls. He informed staff that he had received notification from Mr R of the 2nd January appointment.

2.6.24

On 30th December the ward received a telephone call from the Serious Incident squad at Hendon Police Station asking for information about his whereabouts following the discovery of the dismembered bodies of Elizabeth Valad and Bridgitte Maclennan.

2.6.25

There was no further contact with Mr Hardy until he was arrested on 3rd January 2003.

3.3.1

One of the factors which weighed with the hospital managers when they decided to discharge Mr Hardy from detention under the Mental Health Act was that they believed he was dealing with his alcohol problem. We think the view they took was reasonable. He had conscientiously attended and participated in groups and had said on a number of occasions to nurses that he wished to moderate his drinking. We consider that further prolonging his in-patient stay would not have increased the likelihood that this long-standing problem would have been resolved.

3.3.2

The position had been correctly stated by Mr V, as quoted in paragraph 3.2.2: the test would be when Mr Hardy was free to make his own choices. What happened was that, following discharge, he missed an appointment with Mr V on 18th December 2002 and sent him a Christmas card in which he wrote “I decided I don’t need AAS any more thanks for all your help”. On 19th December Mr V completed a discharge form, which recorded the missed appointment and the message in the Christmas card, and advised that Mr Hardy could be referred again by services or could refer himself. A copy of the discharge form was sent to Dr E, who had also been informed by telephone of the missed appointment on 18th December.

Note: I would draw the reader’s attention to the final sentence of 3.3.2 above

I quite agree but it was homicidal mania that was Hardy’s problem, not alcohol, which he used as a defence mechanism; I find it very strange that mental health professionals found Hardy’s behaviour ‘normal’ while he was busy committing murders. Patients at the psychotic end of the spectrum are very unlikely to commit grossly aberrant acts and present as normal; certainly in my experience as a carer at the ‘hard end’ for the best part of three decades. Chapter 4 deals with community mental health services, biginning with five bullet point questions.

• Were services justified in managing Mr Hardy in the community, rather than as a long-term hospital patient?

• Why was he not visited at home as part of the care plan?

• Why did the regular meetings with his care co-ordinator take place in a cafe?

• Was there adequate communication between the CMHT and other community services?

After a catalogue of violent incidents vulnerable people (including attacks on prostitutes) Hardy was sectioned to a secure unit but kept there for only ten days. From the evidence presented he was highly manipulative. There seems to have been considerable concern for Hardy but little concern for his victims and for the safety of society in general. Sufficient forensic evidence could have been gathered to have Hardy removed to a special hospital but there was no will to do so.

I hardly think a day hospital was, as proposed, the answer. I have considerable knowledge of the excellent care they provide but they are certainly not intended to deal with the likes of Anthony Hardy. The CMHT was incredibly and dangerously naïve. Hardy kept on about studying various subjects and met his key worker casually in a café. What kind of level of supervision was this supposed to represent? The report states ‘he was been effectively managed in the community’ (p.53).

It is our view that the events of January 2002 did not provide a basis for changing fundamentally the way that Mr Hardy was managed.

NOBODY IS RESPONSIBLE is what this means. The naivety of the inquiry is colossal. For example reporting to his key worker that he had cut down and was then only drinking two pints a day. The general picture was reassuring.

No one, but no one, believes an alcoholic about their alcohol dependence. This ‘taking words for deeds’ is symptomatic of the whole report.

Hardy should have been visited regularly at his home. He did not want this – after all one naked dead body had already been found there! The lurid photographs of Hardy’s flat in the aftermath of his trial shows just how useful home visits would have proved. The terrifying fundamental naivety of the inquiry members mirrors that of Hardy’s CMHT workers.

4.4.11

Mr Hardy was also attending the Diorama in 2001. Diorama is a voluntary sector resource. As far as we are aware there was no agreement between the CMHT and Diorama for the exchange of information about individual mental health service users. The only communication of which we have been told was on 18th January 2002 when a member of staff at Diorama telephoned the CMHT manager and reported that Mr Hardy had spoken at Diorama about cannibalism. We have not found any record of this conversation but the CMHT team manager has confirmed that it took place. We have been told by staff at Diorama that Mr Hardy’s were made in the course of a general discussion about the fictional character Hannibal Lector. The next occasion when Mr Hardy was psychiatrically was following his arrest on 20- January, when he did not appear to be psychotic. It is difficult to know what weight to give to the reported remarks of 18 January.

The case for Hardy’s continued detention was summarized by Dr E:

Mr Hardy has a long history of bipolar affective disorder. His mental illness is complicated by alcohol dependence syndrome. There is a serious forensic history, including the attempted murder of his ex-wife. Mr Hardy’s mental illness is controlled by treatment, but he is very vulnerable to relapse. He habitually responds to stress by drinking heavily and he also uses alcohol to elevate his mood. His use of alcohol compromises his compliance with treatment and increases his vulnerability to mood symptoms. Non-compliance with treatment, increasing use of alcohol and escalating manic symptoms combine in a vicious circle during relapses of his illness. His illness is of a nature to warrant his detention in hospital in the interests of his health and for the protection of others. I strongly recommend that his discharge should be a gradual process: once his accommodation has been arranged he should have increasing extended leave at home, combined with attendance at an alcohol day programme and regular monitoring of his mental state.

Throughout the inquiry report there is a scandalous lack of concern for the victims and their families. The evidence of Hardy’s gross mismanagement is in the report for all to see. It was available on the North Central London Strategic Health Authority’s website and also on Camden Council’s. Following a peak time programme on Australian national television two days ago the relevant parts of the site were mysteriously suspended. I wonder why!

Barry Tebb

5 March 2006