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Fear and freedom

Posted: 14 April 2005 | Subscribe Online


It is hard not to be intrigued by the tale of a man who kills a mate and then fries and eats his brains. But, as he was a psychiatric patient at the time of the killing, “who let him out?” is the question that most people have been asking. It later turned out that Peter Bryan had killed before and had spent time in a secure hospital before his release back into the community.



The case of the “cannibal”, as Bryan has become known, has reignited the debate about care in the community for mental health patients. Few people can believe that professionals could have deemed him well – and safe – enough to be let out of hospital twice. The public wants to know just how safe care in the community can be if mistakes as grave as these still happen.


It hasn’t helped that the case of Bryan followed on the heels of another killing by a mental health patient. John Barrett, who like Bryan was a paranoid schizophrenic, stabbed a man to death after being allowed leave from a psychiatric hospital. He had also been violent before. Again the question has been asked: why didn’t the staff involved detect the risk he posed to society?

These two cases are not isolated examples of homicides by people with diagnosed mental health problems. Nine per cent of killers in England and Wales have been in contact with mental health services in the year preceding the offence, and almost a fifth have had contact at some point.( 1)


In the past 10 years there have been more than 150 independent inquiries into homicides carried out by psychiatric patients, and the findings seem strikingly familiar. The evidence often points to a catalogue of errors by the mental health services involved, usually due to poor communication, inadequate risk assessment or lack of face-to-face contact with service users.




One of the most well known inquiries followed the death of Jonathan Zito, who was stabbed to death in December 1992 while waiting for a London tube train. The report into the care of his schizophrenic killer, Christopher Clunis, revealed that three months before the attack Clunis had been discharged from psychiatric hospital into the community.

More than 10 years later, what is still going wrong?


Part of the problem is that many of the old institutions have been shut without enough replacement provision in the community, says Michael Howlett, director of the Zito Trust. The 150,000 beds that were available in the 1950s have now been reduced to fewer than 33,000 and the remaining psychiatric hospitals are buckling under the strain.


“You have to be pretty ill to get into hospital and there is a risk of being discharged before you are ready. This puts even greater pressure on community-based services,” says Howlett.


“We feel there are people in the community who shouldn’t be there. They should be back in hospital. They have been abandoned or forgotten or gone off the radar screen and not adequately followed up. Even if they were known about, it would be almost impossible to find them any hospital services, because they are overstretched.”


That mental health services are at crisis point is not in itself a revelation. For years the sector has been under-funded, and despite mental health being declared one of the government’s top three health priorities, funding has lagged behind other areas.


About one in three people who approach services are turned away. Without the help they need, their condition often deteriorates until they become seriously unwell.


A more preventive strategy is vital if care is to get better, says Tony Zigmond, vice-president of the Royal College of Psychiatrists.


“You won’t prevent tragedies by targeting tragedies. If the aim is to reduce the number of homicides, general improvements in mental health services in the community and in hospitals will achieve this,” he says.


But while any homicide is one too many, it is important to keep a sensible perspective on the number carried out by psychiatric patients. Every year there are about 50,000 detentions under the Mental Health Act 1983, and most people are subsequently discharged back into the community.


“You are 10 times more likely to be killed by your employer than by someone with a mental illness,” says Zigmond. “There are 400 deaths due to corporate manslaughter every year and just 40 by the mentally ill.”


It’s just that when such homicides happen, they tend to reach the headlines. Staff find themselves pilloried for their mistakes which, with hindsight, seem avoidable. Surely this climate of fear must make staff reluctant to take risks?


Absolutely, says Zigmond. “That’s why the number of people detained has doubled in the past 20 years, though there’s not been a doubling in the amount with mental illness. People are being detained more readily and kept in.”


L earning how to assess the risk that a patient poses, either to themselves or to others, is a fundamental requirement for staff working in mental health services. However, that doesn’t mean training is always available or accessible. Even when it is, practitioners often find they cannot spare the time away from clinical duties.



Steve Morgan runs a practice development consultancy and trains people on risk assessment. In an attempt to tighten up their procedures and cover their backs, organisations are increasingly turning risk assessment into an administrative, form-filling exercise.


“The narrow focus on paperwork is a knee-jerk reaction to what is portrayed in the media. But making sure the paperwork is done distracts from the real assessment of risk in day-to-day work,” he says.


Morgan adds that the fear of getting things wrong – from organisations and practitioners – ultimately has a detrimental impact on service users.


“They say that when stories hit the headlines, trusts become more negative and restrictive. Practitioners are worried that if it happens to them they will be on the front page. A substantial number of people are not receiving the services they need and deserve because practice is being driven by a fear of things going wrong.”


If services are no longer of benefit to users, then the users stop coming to them. And if users stop accessing help when they need it, their mental health is likely to suffer and the risks increase.


The system may not be working as smoothly as it could, but are things set to change with new mental health legislation? Not if the draft mental health bill goes through parliament, assuming that it is revived in its current format in the next parliament.


“It could make the situation worse,” says Paul Farmer, chair of the Mental Health Alliance, a coalition of more than 60 mental health organisations campaigning on the proposed changes.


For a start, the way the bill is framed – particularly with its wide definition of mental disorder – could lead to more people being subject to its powers. Receiving help early reduces risks, but if an individual thinks they may be locked up, they will be reluctant to seek help.


In addition, the bill is seen to disproportionately emphasise the danger posed by people with mental health problems. Under the proposals, people who are considered dangerous, such as those with personality disorders, could be locked up indefinitely – despite evidence suggesting that between 2,000 and 5,000 people would need to be detained to prevent just one homicide.
Again, fear and society’s negative perceptions of mental illness, are likely to drive people away from the help they need.


The joint parliamentary scrutiny committee that analysed the bill has made it clear that public protection should not be allowed to dominate reform of mental health legislation.( 2) But in light of the outcry over the recent homicides, the government may not heed the warnings.


To this end, Farmer is concerned. “The danger is there will be a knee-jerk reaction on the back of these two cases, which are extremely rare if you look at the number of people with mental health problems who pose absolutely no risk. We have to frame the legislation to meet the needs of many.”


Exactly what shape the legislation will take remains to be seen. Up until now the government has remained determined to focus on public protection, despite calls for mental health legislation to be primarily concerned with patients. It is to be hoped that any amendments to the bill are written before anyone else is killed – otherwise one dreads to think what draconian measures they could contain.


(1) Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Department of Health, 2001

(2) Report of the Joint Committee on the Draft Mental Health Bill, 2005, from www.publications.parliament.uk/pa/jt/jtment.htm

'Good support means everything'

Martin Reynolds, 43, suffers from schizoaffective disorder. He has had three hospital admissions - an eight-month stint in 1995, three months in 1996, and a week in 1997. In between admissions he has lived in the community.

"In 1995 when I first came out of hospital, care in the community was terrible. I was dumped in a flat on the worst housing estate in the area and told to get on with it. It was not conducive to my mental health at all," he says.

During this time his home was broken into eight times and he was abused and threatened in the neighbourhood. As for care from mental health services, he had infrequent appointments with a psychiatrist and none with a social worker or community psychiatric nurse (CPN).

But he says that the NHS has improved in the past 10 years and he now has weekly visits from a CPN. At last he feels that he is receiving enough support. And what does it mean to him?

"Good support in the community means everything. I made a couple of suicide attempts in the past and it's possible that if I didn't have enough support self-harm might be an option again."

As for the recent hype around homicides by people with mental health problems, he thinks that the public could misunderstand.

"I wouldn't like people to get the impression that all people with a diagnosis are a risk to the public. I'm not a threat to anybody. I'm a very peaceful man.

"He thinks that the public - and the government - should heed the statistics showing the tiny percentage of people with mental health problems who commit crimes.

He adds: "I hope the government doesn't round them up and get them in hospital when there is no need for it."