An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 30^th and 31^st days of July, 1^st, 2^nd, 28^th, 29^th and 30^th days of August, 18^th day of October, 1996 and 28^th day of October, 1997, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Gwenneth Doreen Isobell Hogarth.

I have conducted this inquest as part of a series of six inquests in all. These inquests were into the deaths of Nandadevi Chandraratnam, who died on 3 December 1992, Gwenneth Doreen Isobell Hogarth, who died on 23 July 1993, Consiglia Ciampi, who died on 8 October 1994, Matthew Selwyn Proctor, who died on 28 March 1994, Peter James Lewin, who died on 14 May 1994, and Bernard John TenHoopen, who died on 28 July 1994.

This introduction will appear at the commencement of the findings in all six cases. An analysis of the circumstances of each individual case will follow, and I will then attempt to draw together common themes, in order to make recommendations pursuant to Section 25(2) of the Coroners Act. This analysis will also appear in all six findings.

The six inquests can be divided into two groups, and were heard in that way.

The first group involved the deaths of three people (Gwenneth Doreen Isobell Hogarth, Consiglia Ciampi and Nandadevi Chandraratnam) by homicide, and in each case the perpetrator was found not guilty by reason of insanity. In the first two cases, mothers were killed by their sons, and in the third, Dr. Chandra was killed by her patient. In each case the perpetrator was suffering from either schizophrenia or schizo-affective disorder.

The second group also involved the deaths of three people (Matthew Selwyn Proctor, Peter James Lewin and Bernard John TenHoopen) in separate incidents, within the space of four months or so. Each of these people were patients of Glenside Hospital at the time, either as inpatients or recently discharged outpatients, and each suffered fatal injuries from a passing train after laying on or near a railway track. All three of them suffered from either schizophrenia or schizo-affective disorder.

In all six cases, a detailed analysis of the psychiatric treatment provided to the patients was analysed and reported on by Professor R.D. Goldney, Professor of Psychiatry at the University of Adelaide and a consultant psychiatrist at the Adelaide Clinic. Professor Goldney also gave oral evidence in each of these cases, and I am greatly indebted to him for his thoughtful, thorough and helpful analysis in each case.

The families of the deceased were represented by either Mr. P. Charman or Mr. W. Braithwaite. Various hospitals and health services were represented by Mr. J. Homburg, and doctors were represented by Ms. M. Venning. Other counsel appeared for particular people as the inquests proceeded. No objection was taken by any counsel to the grouping of the inquests in the way I have outlined.

In each case, the patient’s history, the progress of his treatment, and the events leading up to the death were analysed. A number of common issues emerged which, in my opinion, carry serious implications for the psychiatric profession and for the providers of mental health services generally.

The following explanations and definitions may be helpful.

Schizophrenia is described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition ("DSM IV") as follows:-

"The essential features of schizophrenia are a mixture of characteristic signs and symptoms (both positive and negative) that have been present for a significant portion of time during a 1-month period (or a shorter time if successfully treated) with some signs of the disorder persisting for at least 6 months. These signs and symptoms are associated with marked social or occupational dysfunction. . . . The characteristic symptoms of schizophrenia involve a range of cognitive and emotional dysfunctions that include perception, inferential thinking, language and communication, behavioural monitoring, affect, fluency and productivity of thought and speech, hedonic capacity, volition and drive, and attention. No single symptom is pathognomonic of schizophrenia; the diagnosis involves the recognition of a constellation of signs and symptoms associated with impaired occupational or social functioning".

(p.274)

DSM IV describes this condition as follows:-

"The essential feature of schizo-affective is an uninterrupted period of illness during which, at some time, there is a Major Depressive, Manic, or Mixed Episode concurrent with symptoms that meet criterion A for schizophrenia (the "characteristic symptoms"). In addition, during the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. Finally, the mood symptoms are present for a substantial proportion of the total duration of the illness".

(p.242)

At p.273, DSM IV defines psychosis, in the context of schizophrenia, schizo-affective disorder, and other similar conditions, as delusions, any prominent hallucinations, disorganised speech, or disorganised or catatonic behaviour. The term has other shades of meaning in the context of different illnesses.

Professor Goldney told me that all six patients had a severe form of the illness. He said there is usually a chronic gradual deterioration in such patients, although not all cases take such a "severe malignant course" (T.718). He said that both schizophrenia and schizo-affective disorder are reasonably common in the community, and that ideally the treatment should focus on the schizophrenic component first, usually with anti-psychotic medication as a basic step, which also often helps with the depressive ("affective") symptoms as well. Anti-depressants are also used to deal with the depressive symptoms (T.719).

Professor Goldney said that the prognosis pattern is usually divided into thirds. One third of patients do quite well, a third do very poorly, and a third have relapsing and remitting conditions (T.720). He said:-

"Once you have had a schizophrenic illness, you always retain that propensity to have a further episode, and if you are in that poor prognosis, that third group, you will have essentially an unremitting condition which may be controlled at times to a varying degree, but it can be a very nasty illness which does persist".

(T.720)

He said that alcohol and drug abuse, both of which were prominent in a number of these cases, makes the illness much more difficult to treat (T.721), and that, although the illness often has a highly unpredictable path, a "longitudinal view", that is a knowledge of the history of the illness and its patterns, "is usually the best predictor of how things are going to happen in the future" (T.730).

This "co-morbidity" between schizophrenic illness and drug abuse should call for a united effort between mental health services and drug and alcohol treatment services. Unfortunately, prior to 1995, there was, in the words of Dr. Harry Hustig, the Director, Extended Care, at Glenside Hospital, a "very clear gap in communication" between them, and that a number of patients were regarded by one agency as the patient of the other, and hence "fell between the gaps" (T.407). He said that the situation hit crisis in 1995 when there was total confusion as to where intoxicated people with a mental illness should be taken, with neither service wanting to be involved with them.

He told me that a working party was established, and a protocol developed whereby the mental health agencies see such patients first, to deal with the issue of "suicidality", and the patient can later be referred on to the other agency. Although this constituted an improvement in the system, there remained a need for cross-education between agencies (T.408).

Dr. Hustig told me that there is a very high risk of suicide in patients with chronic schizophrenia, of the order of 10%. He said that some of the academic literature puts the risk as high as 50%, although South Australian figures are considerably lower than that (T.191).

There is also a higher rate of familial violence involving such patients. Dr. Craig Raeside, a Consultant Forensic Psychiatrist at James Nash House, has done some informal research which shows that 90% of those people who kill a parent have schizophrenia. He said that the violence was usually limited to intra-familial situations, with a pattern of escalation over time, meaning that close family members of people with schizophrenia are more at risk (T.578).

I have already mentioned that anti-psychotic medication is used to treat patients with schizophrenia. Unfortunately, most of the medications have side-effects which are unpleasant and this often leads the patient to be resistant to medication, sometimes against his own best interest. The side-effects are described as extra-pyramidal, or parkinsonian-type (since they mimic the symptoms of Parkinsons disease). They include disorders of muscle tone (dystonia), tremor, and muscle spasms which can be particularly frightening and painful. The longer-term side-effects include tardive dyskinesia (involuntary facial, shoulder and trunk movements), which is difficult and slow to respond to treatment (see the evidence of Professor Goldney at T.723). There are some medications (for example, Benztropine) which can control some of these effects.

This issue is particularly difficult to deal with since the patient often lacks insight into his condition which, when combined with the unpleasantness of the side-effects, makes him resistant to treatment.

Professor Goldney said that it is almost mandatory to change medication when it appears ineffective or is producing side-effects, since people respond to drugs differently. Another drug may be effective without the side-effects.

The main difficulty is in assessment of when a patient is stable, so that the medication can be reduced, and the patient’s quality of life can be improved. Professor Goldney said:-

"It is mandatory to (reduce medication if the illness is in remission) because the risk of long-term side-effects - for example, tardive dyskinesia, the risk increases the longer you are on a higher dose, and so it does behove one to try and reduce it. And then you have to weigh that up against the risk of relapse and the longitudinal history of what has happened when it has relapsed. And, again, it is a matter of trying to weigh up that clinical dilemma of the risk of side-effects against the risk of illness".

(T.726)

He emphasised that it is "absolutely essential" to monitor the effect of reducing the dose, and to ensure that sufficient time, at least three months, is allowed at each level so that a correct assessment can be made of the affect of the reduction, since the medication (particularly that which is administered intra-muscularly) can be long-lasting in its effectiveness.

For this reason, careful periodic mental state assessments, and appropriate note-taking of both positive and negative symptoms, are essential in order to obtain a "longitudinal view" of the patient’s progress.

Of course, this has been a necessarily brief and superficial analysis of the various aspects of schizophrenic illness. However, it is with these factors in mind that I will now proceed to analyse the particular circumstances of each case.

At about 3.45p.m. on 24 July 1993, Eugene Hogarth, the grandson of Gwenneth Hogarth, attended at her home unit at Hawke Road, Murray Bridge to borrow the lawnmower. As the side gate was open, he walked around to the back yard and noticed an old chair had been placed below the toilet window, and that the wire screen was missing. He looked in through the window and noticed a mess on the lino floor which appeared to be either dirt or blood. He walked back around to the front of the house and knocked on the front door and gained no response. He drove away, but having driven only a short distance he changed his mind, and returned to the house. He felt that there was something wrong. When he got back, he knocked on the front door, and again received no response. Returning to the front door a third time, he heard the dog barking inside and then heard a voice, which he recognised as that of his uncle, Geoffrey Hogarth. After Eugene had identified himself and asked to speak to his grandmother, Geoffrey said "I’m busy, go away", and then "She’s asleep. I don’t want to wake her up".

Eugene checked with a neighbour and confirmed that his grandmother had not been seen for a few days. He drove around to his mother’s house and returned with his mother to Hawke Street. Geoffrey again refused to open the door, so the police were called. After Eugene’s mother became upset and ripped off the flywire from a back bedroom window, he entered the house and found a large rock with blood all over it near the bedroom door. Fearing the worst, he immediately jumped out through the window again, took his mother to a neighbour’s house and rang the police and told them what he had seen (Exhibit C.36a).

Police attended the scene at 4.06p.m. that afternoon, and discovered Mrs. Hogarth’s body. Geoffrey Hogarth was arrested and taken to the Murray Bridge Police Station, where he was later charged with murder (see the statement of Senior Constable Elliott, Exhibit C.38a, p6).

When they entered the unit, police officers found Mrs. Hogarth’s body lying on the floor in the main bedroom. Senior Constable Heath said that he noticed that she had "extensive head injuries" (Exhibit C.41a, p4). He noted large amounts of blood on the floor and some blood on the walls and ceiling. He also noted the blood-stained rock on the floor of the second bedroom.

At 7.18p.m. that evening, Dr. R.A. James, forensic pathologist, attended Mrs. Hogarth’s unit and made an examination of her body. Dr. James’ description was less of an understatement. In his words, "the head had been pulped" (Exhibit C.34a, p2).

Dr. James also noted the presence of eight separate stab wounds in the tissues of the neck, particularly behind the right ear. No haemorrhage or bruising was present adjoining the stab wounds, suggesting that they may have been made after death.

Dr. James’ conclusions were as follows:-

1. The fact that Mrs. Hogarth’s body had cooled to the environmental temperature implied that death had occurred at least 18 to 24 hours previously. The absence of putrefactive change suggested that her death probably occurred on the evening of Friday 23 July 1993;

2. Mrs. Hogarth’s head was crushed as a result of multiple blows with a blunt object. It was not possible to assess the number of blows, but clearly many blows were responsible. The pattern of injuries was consistent with infliction by the large rock found in the adjoining bedroom (p.12);

3. The post mortem injuries to her neck suggested that there had been an attempt at complete decapitation (p.13).

At 7.15p.m. that evening Dr. M.J. Beckoff, a general practitioner who practises at Murray Bridge, who had previously treated Geoffrey Hogarth, attended at the Murray Bridge Police Station and conducted a medical examination of him. Following the examination, and at Dr. Beckoff’s direction pursuant to the Mental Health Act, Geoffrey Hogarth was transferred to James Nash House, a secure psychiatric facility where he has remained ever since.

On 25 July 1993, Dr. Beckoff’s detention order was reviewed by Dr. Paula Lagnado, a psychiatrist, in accordance with the Mental Health Act. According to the casenotes, she found Geoffrey Hogarth to have been psychotic, with manifestations of persecutory delusions, and that he was guarded, defensive and irritable. She confirmed the detention order (see the report of Dr. O’Brien, Exhibit C.46a, p5). In subsequent examinations of him, Dr. K.P. O’Brien, the Director of Forensic Services at James Nash House, was completely satisfied that he was psychotic, finding him vigilant, hostile and paranoid. Although he did not display obvious features of thought disorder, he found him to be internally pre-occupied by what Dr. O’Brien suspected to be delusional material and hallucinations (Exhibit C.46a, p5).

Dr. O’Brien said that Mr. Hogarth’s dosage of Haloperidol (Haldol), an anti-psychotic medication, was "substantially increased" and was later changed to another anti-psychotic medication, Flupenthixol.

On 3 June, 4 July and 21 July 1994, Mr. Hogarth was interviewed by Dr. William Lucas, forensic psychiatrist, at the request of the Director of Public Prosecutions. Dr. Lucas’ report is Exhibit C.45a. Dr. Lucas’ diagnosis was that Mr. Hogarth suffered from chronic schizophrenia, which did not appear to have been in remission for any substantial period. He said that Mr. Hogarth’s delusional beliefs were such that, although he understood the nature and quality of his act in killing his mother, he could not appreciate its wrongness with an appropriate degree of sense and composure (p.10).

On 26 September 1994, Geoffrey Hogarth was found not guilty of the charge of murder of his mother on the grounds of insanity by the Honourable Justice Cox, sitting in the Supreme Court of South Australia without a jury. Pursuant to Section 292(2) of the Criminal Consolidation Act, His Honour directed that he be detained in a secure psychiatric institution until further order of the court.

Geoffrey Lachlan Hogarth was born on 24 June 1952. According to his sister, the first signs of mental illness began appearing in his early 20’s. She said that when he was about 23 or 24 he inflicted quite severe head injuries on himself and almost lost the sight in one eye as a result. He had obviously developed paranoid ideation. He said that people had been following him, the Mafia were on to him, that his flat had been ransacked and the like. She also referred to another incident at Largs Bay when he barricaded himself in the house. He thought that people were in the ceiling, and he was firing a gun off inside the house. As a result of this incident he was detained and taken to Glenside Hospital (Exhibit C.73, p1).

A letter from Dr. J. Gipslis, Senior Psychiatrist at Hillcrest Hospital, to Dr. G. Smith of Glenside Hospital dated 19 June 1985, which forms part of the Glenside Hospital casenotes (Exhibit C.70), contains a useful summary of his early psychiatric treatment:-

• in 1972, then aged 19, he was voluntarily hospitalised for a period of six weeks with a diagnosis of acute schizophrenic illness. He was discharged on medication, but failed to attend follow-up;

• in February 1977 he was interviewed by Dr. Carl Radeski, forensic psychiatrist, at the Adelaide Gaol. Dr. Radeski found him to be acutely psychotic and considered the most likely diagnosis to be schizophrenia. Although Dr. Radeski suggested that he be hospitalised, this did not take place;

• in August 1978 he was admitted to hospital with an acute exacerbation of schizophrenic illness and remained in hospital until 6 October 1978. Again, he failed to attend for ongoing treatment;

• in 1979 he was re-admitted as a certified (detained) patient for a period of two months arising out of an incident where he had been arrested by police when in possession of firearms (presumably, this is the incident described by his sister at Largs Bay). Again, a diagnosis of acute schizophrenia was made. Although he continued to be treated as an outpatient until October of that year, he failed to continue with that treatment when his treating medical officer left the hospital;

• in October 1980 he was detained again and admitted to Hillcrest Hospital under the care of Dr. Gipslis. Again the diagnosis was acute relapse of schizophrenic illness. He had ceased taking medication about eight months prior to his hospitalisation. She noted a history of threatening his mother with violence, together with other paranoid delusions of various types. Dr. Gipslis referred to the number of psychotic episodes he had suffered since the age of 19, his premorbid schizoid personality, and his history of poor compliance with treatment. On 12 December 1980 an order was made for his guardianship, and an order for psychiatric treatment was made;

• in December 1981 he failed to attend an appointment with Dr. Gipslis as he and his mother had moved to Murray Bridge, so she wrote to a general practitioner, Dr. Michael Beckoff, in Murray Bridge and also spoke to him and confirmed his willingness to treat Mr. Hogarth. Dr. Gipslis said that she also advised the Guardianship Board of Mr. Hogarth’s move, and that the transfer of responsibility for his treatment to Dr. Beckoff was accepted by them;

• Dr. Gipslis saw Mr. Hogarth on several occasions after that time, notably in November 1982, August 1984, September 1984, and December 1984, on referral by the Guardianship Board.

Professor Goldney confirmed Dr. Gipslis’ opinion concerning Mr. Hogarth’s history. He said:-

"It is evident that Mr. Hogarth has had a severe paranoid schizophrenic illness from about the age of 20, with repeated relapses associated with non-compliance of medication. His illness has been characterised by lack of insight, a tendency to develop side effects from medication, and a repeated history of appeals and attempts to obtain assistance to reduce medication whenever possible".

Mr. Hogarth’s last admission to Glenside Hospital commenced on 2 January 1992 and lasted until 5 February 1992. He had been detained by Dr. Beckoff pursuant to the Mental Health Act. In the "Order for Immediate Admission and Detention", Dr. Beckoff stated:-

"Geoffrey is a chronic paranoid schizophrenic who hasn’t had any treatment for some time and is now quite irrational and a danger to himself and his neighbours. His mother is even frightened to visit him.

Please note: He should be once again under the Guardianship Board with a treatment order as he was previously".

(see casenotes, Exhibit C.70)

The assessment made at Glenside was that he had suffered a "relapse of schizophrenia secondary to non-compliance". He was discharged on the basis that he should receive an intra-muscular injection of Haloperidol (Haldol) at the dose of 25mg each week.

This reference back to Dr. Beckoff in Murray Bridge was made despite the fact that concern had been expressed about whether this was appropriate. In a report of the social worker, Ms. Quick, dated 20 January 1992, it was noted:-

"Mr. Hogarth has a long history of resistance to taking medication and becoming aggressive and violent towards those caring for him. When he is psychotic police have been involved. Mr. Hogarth has expressed an intense dislike of Modecate in the past . . . I doubt that there are sufficient resources in Murray Bridge given Mr. Hogarth’s ability to avoid compliance in the past".

(Exhibit C.70)

In any event, Dr. Beckoff continued with Mr. Hogarth’s treatment following his discharge, and on 24 March 1992 the medication was changed to 50mg every two weeks, and then in April 50mg every three weeks, and by 1 May 1992 they were being given every four weeks, and this was still the case in September of that year (see Professor Goldney’s report, Exhibit C.81b, p3).

I have already mentioned that Mr. Hogarth was discharged from Glenside Hospital on 5 February 1992. The discharge summary was prepared by Dr. Carol Fraser (T.408), who was then a trainee psychiatrist. Part of the discharge summary reads as follows:-

"It has been noted that Mr. Hogarth has some abnormal mouth movements which were not noted on admission. However, he remains mildly thought-disordered and it is felt the benefits of his medication outweigh the side-effects. He has complained of slight tremor and dry mouth but he refuses oral medication".

(see the casenotes, Exhibit C.70)

I take Dr. Fraser’s reference to "abnormal mouth movements" to be a reference to the side-effect of anti-psychotic medication known as "Tardive Dyskinesia".

Despite Dr. Fraser’s advice, Dr. Beckoff reduced Mr. Hogarth’s dosage of Haloperidol (Haldol) from 50mg every two weeks to 50mg every three weeks. He did so because of Tardive Dyskinesia, although he made no comment about Mr. Hogarth’s mental state in his casenotes at the time (T.111).

On 1 May 1992, Dr. Beckoff reduced the medication level again from 50mg every three weeks to 50mg every four weeks. This was the next time Dr. Beckoff saw him after the previous reduction on 10 April. Dr. Beckoff made no assessment of the effect of the reduction made on 10 April before reducing it again on 1 May, and there is no record of any mental state assessment in his casenotes. However, Dr. Beckoff said in evidence that these reductions were made because of Mr. Hogarth’s complaints of Tardive Dyskinesia (T.111). I will deal with this issue again later.

On 10 July 1992 Mr. Hogarth was seen by Dr. P. King, a psychiatric registrar at Glenside Hospital, and she continued to see him during his periodic visits to Glenside Hospital until January of 1993. On that first occasion Dr. King conducted a full mental state examination of Mr. Hogarth and found signs of Tardive Dyskinesia but no sign of extra-pyramidial side-effects (Parkinsonian symptoms such as tremor and muscle spasm). She found no perceptual disturbance or thought disorder, although he was dishevelled, a little oddly dressed, and insistent that he wanted his medication reduced even further.

She declined to reduce his medication, partly because this was her first consultation with Mr. Hogarth, and secondly because it had only recently been reduced (T.163).

On 8 September 1992 Dr. Beckoff wrote a letter to the Guardianship Board in which he described Mr. Hogarth’s condition as follows:-

"Geoffrey has certainly settled at the current time and is probably as good as I have seen him".

(the Guardianship Board file is Exhibit C.69)

On 11 September 1992 Mr. Hogarth attended at Glenside Hospital and was seen by Dr. King. She noted some persecutory ideas, and the fact that he was arguing about the need for medication, describing him as "angry + + +" (T.163). Again, Dr. King elected not to reduce his medication level despite his insistence to the contrary.

Professor Goldney pointed to the contrast in the assessments of Mr. Hogarth made by the two doctors only three days apart. Dr. Beckoff’s rather sanguine view of his condition certainly was in stark contrast to Dr. King’s concern about his mental state to the extent that she was not prepared to reduce his medication level.

Professor Goldney pointed out that it is sometimes extremely difficult to elicit and detect psychotic symptoms in some patients. Mr. Charman, counsel for the Hogarth family, had asked Dr. Beckoff:-

"Q. Is it possible for a person to be psychotic, but be able to hide that from a person for some period of time?

A. I think if a person is psychotic they are psychotic and it’s usually pretty obvious".

(T.122)

Professor Goldney disagreed with that proposition, pointing out that Dr. Beckoff’s view may indicate he was inexperienced in dealing with psychotic illness. He said:-

". . . because it’s just not reality. It can be very very difficult to elicit symptoms of psychosis in some patients".

(T.783)

Professor Goldney said that if Dr. King was able to elicit symptoms of psychosis on 11 September 1992,

"I bet my bottom dollar he also had them on 8 September, but I would submit that a trainee psychiatrist, a good conscientious trainee psychiatrist has probably spent the time, is having the experiential training to elicit that".

(T.784)

I will deal with this issue again later.

On 13 November 1992 Dr. King reduced Mr. Hogarth’s medication from 50mg every four weeks to 25mg every four weeks. On this occasion, she said that he had no psychotic symptoms, although he had some ongoing somatic complaints, and compliance was good, suggesting that he was stable (T.166). However, following this reduction, Dr. King wrote to Dr. Beckoff as follows:-

"As per our telephone discussion, Mr. Hogarth has improved whilst I have been reviewing him in outpatients at the hospital. He exhibits symptoms of Tardive Dyskinesia and as discussed we feel he should decrease his Haldol to 25mg four weekly. This is to be done with close monitoring of Geoffrey’s condition and increased in the event should his mental state deteriorate".

(part of Exhibit C.70)

Dr. King explained that the sort of symptoms she was referring to included verbal aggression and delusions, and any changes in his behaviour or conversation whatsoever (T.167).

On 22 January 1993, Dr. King saw Mr. Hogarth for the final time and transferred him to the care of Dr. B.K. Jha, a consultant psychiatrist at Glenside. Dr. Jha saw Mr. Hogarth for the first time on 23 March 1993. Although he said that he would have conducted a clinical examination at the time, he made no note about that in the casenotes. He said that because there was no mention of psychotic symptoms at the time, they were not present. He said:-

"We actually don’t like to write negative things, we write positive things. The very fact that the mental symptoms had not been documented, proves that he didn’t have mental symptoms at the time, mental symptoms by way of delusions and all that . . ."

(T.419).

This attitude towards notekeeping in psychiatric cases was criticised by Professor Goldney in his evidence, and I will deal with this issue in more detail later.

On 27 April 1993, Dr. Beckoff reduced Mr. Hogarth’s medication again from 25mg every four weeks to 25mg every six weeks (T.114). Again, he explained this action on the basis that Mr. Hogarth was complaining of Tardive Dyskinesia.

On 25 May 1993, Dr. Jha saw Mr. Hogarth in Glenside Hospital Outpatients Department. Dr. Jha referred him back to Dr. Beckoff, on the basis that he was finding it difficult to come to Adelaide for a check-up. Dr. Jha did not formally discharge Mr. Hogarth from the care of Glenside Hospital and did not formally communicate with Dr. Beckoff this apparent change in the arrangements. He simply told Mr. Hogarth to follow up with his general practitioner. Dr. Jha said that, consistent with his earlier practice, the absence of a note in the casenotes is indicative of the fact that there was no psychotic symptoms present at that time (T.420).

Dr. Jha denied that Mr. Hogarth had been discharged from Glenside during this process, although he agreed that his intention was that Mr. Hogarth would continue to be treated by Dr. Beckoff at Murray Bridge without supervision from Glenside. He said:-

"Glenside Hospital had always the responsibility to look after him through Dr. Beckoff, through the community worker at Murray Bridge Hospital".

(T.435)

However, Dr. Jha was quite unable to explain how Glenside would continue to have input into Mr. Hogarth’s treatment unless Dr. Beckoff referred Mr. Hogarth back to them.

Professor Goldney said:-

"It was unexpected to me when his whole management was put over to Dr. Beckoff because I would have anticipated that it should have stayed with Glenside with Dr. Beckoff’s assistance, rather than handing it all over to Dr. Beckoff. I think it is unreasonable to have done so".

(T.775)

Professor Goldney said that this was particularly the case since Dr. Jha’s actions were not accompanied by any written communication to Dr. Beckoff. Professor Goldney said that such advice should have been to the effect that:-

"This patient, Mr. Hogarth, has had his medication reduced from - to - . It is possible that his symptoms would re-emerge. Please don’t hesitate to contact me should that occur, and we’ll increase his medication".

(T.776)

Mr. Hogarth’s sister told me that she had noticed behaviour which she described as "psychotic", including laughing all the time and talking to people who were not there, as well as being aggressive and physically over-bearing around this time. Indeed, she felt that Geoffrey Hogarth’s condition had been deteriorating for some years, and that it was only in the short period of time immediately following a Haloperidol injection that he would be quiet. She also noted the shaking and other Parkinsonian side-effects at these times (T.297).

The last time Geoffrey Hogarth saw a medical practitioner prior to his mother’s death was on 20 July 1993 when he saw Dr. Beckoff and received an injection of Haloperidol. Dr. Beckoff’s note reads:-

"Haldol I/M 25mg. ‘Best I’ve seen Geoffrey for some time’".

(see Exhibit C.69a)

On Dr. James’ estimate of the time of Mrs. Hogarth’s death, this assessment of Geoffrey Hogarth occurred just over three days prior to his mother’s death.

After an examination of Mr. Hogarth’s casenotes, the reports of Doctors Lucas and O’Brien, and the statements tendered at the inquest, together with the records from Dr. Beckoff’s surgery and the Guardianship Board, Professor Goldney summarised Mr. Hogarth’s psychiatric history as follows:-

"It is evident that Mr. Hogarth has had a severe paranoid schizophrenic illness from about the age of 20, with repeated relapses associated with non-compliance with medication. His illness has been characterised by lack of insight, a tendency to develop side-effects from the medication, and a repeated history of appeals and attempts to obtain assistance to reduce the medication wherever possible. . . .

I note these points at the outset as it is quite evident that Mr. Hogarth has had only a very limited degree of insight into his condition and there is a theme running through his history of him trying to reduce medication at all times. . . .

It is important to note that with such a history of repeated relapses with a limited degree of insight, it requires a consistency of management, with ongoing knowledge of what has occurred previously when medication has been reduced, in order that management can remain optimal".

(Exhibit C.81b,p1-2)

A fundamental difference of opinion emerged in the course of this inquest about the propriety of transferring overall responsibility for Mr. Hogarth’s treatment from a specialist centre at Glenside Hospital to Dr. Beckoff, a general practitioner at Murray Bridge. In Professor Goldney’s opinion, this placed too high a responsibility on Dr. Beckoff. I have already referred to Professor Goldney’s evidence about how difficult it can be to detect psychotic symptoms in some patients, especially patients such as Mr. Hogarth, who seems to have been able to hide his symptoms when it suited him.

Professor Goldney said:-

"Dr. Beckoff was in an invidious position in being asked to manage a person with such a severe psychotic condition. I appreciate that there is a push to management within the community for persons with all degrees of psychiatric illness. However, in persons with chronic schizophrenic illness where compliance is a problem, it is critical that experienced clinicians with a body of academic psychiatric knowledge and a continuity of treatment knowledge about individual patients have responsibility for such patients. In my view it places an unfair burden on general medical practitioners asking them to assume a considerable degree of responsibility for the care of such patients".

(Exhibit C.81b, p7)

Although Dr. Jha was the person who made the decision to transfer responsibility to Dr. Beckoff, he said that he agreed with Professor Goldney’s comments. However, he pointed to the fact that it is Government policy to manage patients in the community, and that there is only one psychiatrist to his knowledge, working in rural areas. He said:-

"So if Dr. Beckoff will not see him, who will see this patient?"

(T.429)

Dr. Jha added that Professor Goldney’s comments were

"not in harmony with the changes which are taking place in the management of psychiatric patients, not in the spirit of the community psychiatry".

(T.430)

It seems to me that Dr. Jha’s comments really illustrate the fact that if there is to be a devolution of responsibility for the treatment of psychiatrically ill people to general practitioners in the community, this devolution must be accompanied by a much greater degree of assistance and direction for those practitioners in the day-to-day management of these patients. It should not be assumed that these practitioners have the same degree of expertise and knowledge as may exist in a specialist institution for the treatment of these patients.

In my opinion, this case demonstrates that such assumptions were made in relation to Dr. Beckoff, and that they were not valid. Consistent with Professor Goldney’s evidence, I do not criticise Dr. Beckoff for this. Although perhaps it is true that he should have been more aware of his own limitations, particularly in his ability to detect psychosis, he was the person upon whom all this responsibility was placed, and he was doing his best to treat Mr. Hogarth within the limits of his own psychiatric experience.

There was nothing to prevent an ongoing programme of visits to the Glenside Hospital on a periodic basis, whereby his condition could be monitored. After each visit, adequate communication back to the general practitioner should have taken place so that he might have been aware of any developments in the patient’s condition and so he could have been informed of any changes in his treatment regime.

Professor Goldney pointed out that this was particularly the case where, as here, the patient was having his medication reduced. He said:-

". . . because that is the time of concern when one has to be really on the lookout for a re-emergence of symptoms . . . but when in fact the dose of medication has been reduced and particularly when they are reduced to this extent, the dose of Haldol is very very minimal, and I don’t think it’s good practice".

(T.788)

Professor Goldney was also critical of the frequency with which Mr. Hogarth was seen at Glenside. He suggested that, after he was discharged on 4 February 1992, Professor Goldney would expect that he should have been seen fortnightly for a couple of visits, then, if he was settling down, extend the period to four weeks or so, then perhaps extending it to six and then eight weekly visits, coinciding with his injections. He said that the two month period after discharge before he was first seen was too long (T.810).

At the time of Mrs. Hogarth’s death, Geoffrey Hogarth was receiving Haloperidol Deconoate (Haldol) at the rate of 25mg every six weeks. As I have already mentioned, he received his last dose just over three days prior to her death.

In February of 1992 he was receiving a dosage of 50mg of Haldol every two weeks. That was progressively reduced in accordance with the following table:-

The evidence before me in this inquest is overwhelmingly in favour of the proposition that this dosage was completely inadequate for a person with a condition as severe as Mr. Hogarth’s. A clue as to how this came about may be had from the evidence of Dr. Jha, who gave the following insight into his approach to medication. He said that medication is a very important factor in the recovery of the patient, but that he thought it was more important that the patient had confidence in the doctor because:-

"If he approaches you in a suspicious way, that you are going to kill him, then actually the patient may attack you. So I think that probably it is better to continue treatment with the approval and consent of the patient and we always try to do that. Only when we fail then we try to get the treatment orders".

(T.448)

One might have thought that if the patient’s medication level is adequate, the doctor need not approach his treatment in such a fearful way. At another stage of the evidence, Dr. Jha explained:-

"Sometimes we give heavy dosage of medication actually which does not serve the real purpose with the patient. So probably the skill lies in controlling symptoms with the minimum effective dose of the medicine, not to give the very high dose. This is the current thinking, don’t give high dose, don’t produce side-effects. Side-effects are something actually which interferes in the treatment and it should be avoided as far as possible".

(T.447)

Whatever the reason as to how it came about, as I have said, there can be no doubt that the dose was inadequate. Dr. K.P. O’Brien, the Director of Forensic Psychiatry at James Nash House, who treated Mr. Hogarth after he was detained on 24 July 1993, said in his report to Mr. Hogarth’s solicitors:-

"By the time of Mrs. Hogarth’s death, your client was taking a very small amount of anti-psychotic medication, namely Haldol 25mg every six weeks. Certainly our subsequent experience of Mr. Hogarth at James Nash House would suggest that this dose was inadequate, and he required a very much higher dose".

(Exhibit C.46a, p7)

Dr. O’Brien added that at one stage, they had Mr. Hogarth on a dosage of 100mg of Haldol every four weeks.

Dr. Craig Raeside, a forensic psychiatrist at James Nash House, agreed, saying that a dosage of 25mg every six weeks "is like giving him nothing at all" (T.559). He explained that this equated to a dose of less than .5mg of Haloperidol in oral form, and that the only people that might receive such a dosage would be a disturbed geriatric in a nursing home (T.560).

Professor Goldney also agreed, suggesting that the anti-psychotic effect of such a dose would be minimal (T.779). He said:-

"I would maintain that the dose he was on at the time was such a dose that inevitably he was going to go psychotic again, in view of the history, and there is just no way in the world that it was going to hold his illness at that level. Such a dose may be OK for some people with a relatively mild schizophrenic illness, but with his track record it was just inviting trouble".

(T820)

Professor Goldney said that he was concerned that Dr. Beckoff may not have been aware of the limitations of such a low dose of Haldol. He also voiced similar concerns about the staff at Glenside Hospital (T.778). In those circumstances, I consider that it was the responsibility of the specialist institution, namely the staff at Glenside Hospital, to give Dr. Beckoff guidance as to medication levels and, plainly in this case, that did not occur.

Professor Goldney added that any reductions to the dose should only have occurred in the context of consultations with the experts at Glenside Hospital (T.773-4).

Both Dr. Jha (T.412) and Dr. King (T.165) agreed. Dr. King said:-

". . . I would have hoped that discussions were to occur with me if there were any further reductions in medication".

(T.165)

Unfortunately, no-one told Dr. Beckoff that he should not reduce the medication except with such consultation. He clearly thought it was his responsibility to make decisions in that regard. He said that he was given no guidelines as to how Mr. Hogarth was to be assessed in order to reduce the medication, nor was he given any information or guidelines generally into the treatment of schizophrenia (T.103).

To be fair to the staff at Glenside Hospital, it must be pointed out that at no stage did Dr. Beckoff seek any such guidance or information.

On each occasion on which Dr. Beckoff reduced the medication level, and this also applies to the occasion when Dr. King ordered a reduction as well, the reduction was made because Mr. Hogarth was complaining of side-effects. At no stage did either of those practitioners consider any medication (of which there is a wide variety) to deal with those side-effects. Dr. Beckoff explained that he attempted to control side-effects when Mr. Hogarth had been on Modecate some years ago, but he was not successful and so he did not try that again (T.115). Professor Goldney pointed out that it was not appropriate to have given up so easily. He said:-

"If a person doesn’t respond well to one, one tries the next, and if that doesn’t work one tries the next, that is commonsense I would have thought".

(T.789)

Dr. Jha did not accept that Mr. Hogarth’s medication levels were inadequate, nor did he accept that any such inadequacy may have played a role in Mr. Hogarth’s actions in killing his mother. He said:-

"It appears from the notes that he was given the dose only one week before he committed the murder of his mother, this shows that he had adequate drug level in his body and he was also reasonably well in his mental condition at that time considering his long-standing illness".

(Exhibit C.77, p2)

One only has to examine the grotesque manner in which Mr. Hogarth killed his mother, and the findings of the psychiatrists at James Nash House after his detention, to recognise how misconceived that approach really is. The evidence before me is clear that, at the time he killed his mother, Geoffrey Hogarth was psychotic, and that his level of anti-psychotic medication at that time was so low as to have been worthless.

As I have already mentioned, Professor Goldney said that an illness as severe as that suffered by Mr. Hogarth calls for specialised treatment, and that he felt that a general practitioner was not sufficiently well qualified or experienced to treat such an illness without supervision and/or consultation from specialists. Accordingly, that subject does not require further discussion under this heading.

I have already referred to the fact that Dr. Jha, in the two entries he made in the Glenside Hospital casenotes in relation to Mr. Hogarth, did not record either the presence of absence of psychotic symptoms on either occasion, and that his explanation was that if he had not recorded any such symptoms, they were not present.

Dr. Jha argued that the notekeeping practices at Glenside Hospital were more than sufficient. Indeed he suggested that people at Glenside Hospital wrote in the notes too much. He said:-

"Everybody is writing, writing, and sometimes you don’t have the time to read it, what others have written. The nurses are writing, the social workers are writing, the trainee psychiatrists are writing, the psychiatrists are writing, and you fill volumes and volumes you know. . . . As Senior Consultant Psychiatrists we are not actually - so far as writing the casenotes of a psychiatric patient is concerned, you can write ten pages, more than that, the whole history. But we just try to check up the important symptoms. I know what this person is suffering from . . . I know what are the important features of paranoid schizophrenic and I can check on those symptoms, whether he has those symptoms or not. So probably it depends upon the availability of time".

(T.428)

Both Dr. Raeside and Professor Goldney deprecated this approach, explaining, as they did in other cases, the necessity to make a note of a thorough mental state assessment on each occasion when a patient is assessed, particularly when changes of medication are taking place. Dr. Raeside explained that when a patient may be undergoing a slow deterioration, the small incremental changes in his condition may not be noticeable in consecutive appointments, but if accurate notation is made then one can look back over a lengthy period (perhaps six months or so) and detect a pattern which becomes important (T.574).

Both doctors made similar criticisms of Dr. Beckoff’s notes. Dr. Raeside said:-

"They started off a bit more detailed, and got less and less until they potentially became a list of current medication doses, so I believe that whilst they may be the norm, I believe they are insufficient to monitor the progress of someone with a severe chronic mental illness in the community".

(T.574-5)

Mr. Hogarth’s sister, (name suppressed), made a written statement to the inquiry (Exhibit C.73b). In that statement, she was critical of the lack of support and communication that her family received in trying to deal with her brother. She said:-

"I consider one of the saddest things about what happened to our family is that, on reflection, it seems that there was never any support in dealing with Geoffrey’s schizophrenia. We were not aware of any case plan and there was no information supplied about his condition, even when there was a change of behaviour. There was also no information for us about his treatment, and we were unable to have input about whether we considered his medication was effective or needed to be changed.

After his behaviour diverted from what was considered relatively normal, the things that triggered this was not discussed with us, or analysed or addressed.

On discharge from hospital following treatment, we were left to our own resources and devices. We would have to accommodate him, set him up, there was no support. He would ‘fall down’ again. Only then would anyone come to our assistance.

At times we would have to call the police. The ‘paddy wagon’ would pull up outside the house to collect Geoffrey. The police would try hard but they are not trained to deal with these situations. People who are trained and sensitive to the needs of the person and the family is really important. This was the only form of assistance after Geoffrey had done something which was unacceptable to the community . . .".

Later in her statement, she said:-

"The State and the community must accept responsibility for caring for people with schizophrenia. It is just too big a burden on families".

This is particularly the case since the plight of families is not well understood or recognised in the general community. For various reasons, families of people suffering from schizophrenia may be reticent to make others aware of their plight. (name suppressed) said:-

"I know that my mother would have been highly embarrassed and upset and felt guilty that it was her son, and she probably felt responsible in some way, of course she was not responsible in any way, but yes, I do perhaps think that she may not have raised it because she would have been ashamed that her son was treating her in that way, but I think that that’s a normal, not normal but the reaction of some women of my mother’s age . . . she was a very proud woman".

(T.294)

(name suppressed) then went on to make a number of very sensible recommendations and I will deal with them later in these findings.

I find that Gwenneth Doreen Isobell Hogarth, late of U4, 9 Hawke Road, Murray Bridge, aged 76 years, died at U4, 9 Hawke Road, Murray Bridge on or about 23 July 1993 as a result of traumatic brain damage complicating multiple blows with a blunt object.

Section 25(2) of the Coroners Act provides:-

"A coroner may add to his or her finding any recommendation that might, in his or her opinion, prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the inquest".

Having regard to the similarity of the circumstances of the deaths in this series of inquests, and in particular, to the similarity of the issues relating to psychiatric treatment arising in these cases, I will take into account evidence in each case and draw together a series of recommendations. Before doing so, however, I will discuss the issues under the same series of headings, as follows:-

In two cases, the diagnosis of schizophrenic illness was made at a much later time than it need have been. In the case of Matthew Proctor, Professor Goldney told me that the opportunity for early intervention in this illness is an advantage to treatment. In that case, however, schizophrenia was not diagnosed during his first admission to Glenside. Peter Lewin’s illness was not diagnosed until his third admission to Glenside in 1979. No criticism was levelled in relation to the timing of the diagnosis in the other four cases.

In case those charged with the heavy responsibility of making a diagnosis of schizophrenia are reluctant to do so because, as Professor Goldney suggested, "it’s almost like a death sentence", I consider that it is necessary to remind those people, and particularly trainee psychiatrists and career medical officers, that an early and clear diagnosis of schizophrenia will be particularly advantageous to the patient’s treatment. Once made, such a diagnosis should of course be revisited. But due regard should be paid to the diagnosis throughout the treatment period. This did not occur in the case of Bernard TenHoopen, until he was seen by Dr. Gill, who remembered an earlier stay at James Nash House and put his treatment back on track.

There is clear evidence before me that in all six of these cases, there were serious defects in the psychiatric treatment provided. In Matthew Proctor’s case, staff at Glenside did not come to grips with his psychiatric illness at all, instead concentrating on socio-economic factors, an approach which was doomed to failure in view of the severity of his illness. In Peter Lewin’s case, the difficulties associated with his treatment were largely attributable to a failure to obtain appropriate treatment orders from the Guardianship Board, although Professor Goldney acknowledged the complicating factor of Mr. Lewin’s abuse of anti-parkinsonian medication. In Bernard TenHoopen’s case, Professor Goldney said that he should have been treated in a much more aggressive way. A detailed analysis of the treatment given to David Tzeegankoff was not possible since, tragically, the person who was most responsible for such treatment (Dr. Chandra) is deceased and the casenotes are largely uninformative. In the case of Geoffrey Hogarth, Professor Goldney was critical of a transfer of the responsibility for the treatment of his serious and chronic schizophrenic illness by Glenside Hospital to a general practitioner, thereby placing him in an "invidious position". In the case of Frank Ciampi, the revocation of a treatment order by the Guardianship Board, and his subsequent refusal to receive Modecate in appropriate doses, had a seriously deleterious effect upon his treatment. A lack of communication between the Ciampi family and Carramar Clinic staff was probably the most important factor which led to this situation, and which led in turn to a failure to provide adequate information to the Guardianship Board.

Frank Ciampi’s case is an example of a problem encountered in several of these cases where staff at psychiatric institutions were either reluctant to approach the Guardianship Board for coercive orders, even when the condition of the patient called for such action, or provided inadequate information to the Board, thereby preventing an appropriate decision being made. This problem was also evident in the cases of Matthew Proctor and Bernard TenHoopen.

A common factor in all of the cases in this series was the fact that the levels of anti-psychotic medication prescribed for these patients was inadequate to control their psychosis. In the introduction, I referred to the fact that it is often difficult to achieve a satisfactory balance between, on the one hand, providing an adequate level of medication, and on the other hand ensuring that the level is not so high as to needlessly produce unpleasant side-effects. In Matthew Proctor’s case, Professor Goldney was critical of the fact that on a number of occasions when he presented with psychotic symptoms, his medication levels were not adjusted, and other medications were not considered which may have been more successful. When levels were changed, they were given an inadequate trial before being changed again so that monitoring of the effects of such changes was ineffective.

In Peter Lewin’s case, although his treatment was complicated by his abuse of anti-parkinsonian medication, Professor Goldney was critical of the low dose of anti-psychotic medication he was receiving, and the failure of Glenside staff to increase it after signs of psychosis began re-emerging. Professor Goldney told me that Bernard TenHoopen did not have a satisfactory trial of anti-psychotic/major tranquilliser medication at Glenside Hospital, and the dosages were inadequate. This was particularly apparent in the last few days of his life. This is to be contrasted with the successful course of medication achieved when Mr. TenHoopen was at James Nash House, which should have led to optimism that his condition was treatable. David Tzeegankoff’s medication was also criticised as inadequate, no doubt because he often complained bitterly about the side-effects, thereby putting pressure on his medical practitioners to reduce it. However, Professor Goldney criticised the fact that his mental state was not monitored adequately after reductions took place in the face of recent history of increasing psychotic symptoms. If the medications were unsatisfactory, alternatives should have been tried. Geoffrey Hogarth’s medication was reduced by his general practitioner, and on one occasion by a psychiatry registrar at Glenside, to a level which was completely inadequate for a person with a condition as severe as his, to the extent that Dr. Raeside described it as "like giving him nothing at all". Plainly, Glenside Hospital gave Dr. Beckoff inadequate guidance as to medication levels, nor did they consider medication to control the side-effects as an alternative. Finally, Frank Ciampi’s medication levels were also criticised as inadequate, and again Mr. Ciampi placed great pressure on his treating practitioners, complaining about the severity of the side-effects. Decisions were being made about Mr. Ciampi’s medication levels while his practitioners at Carramar Clinic were ignorant of his violent behaviour, particularly towards his family, when he was not at the hospital.

In my opinion, although it is not possible to conclude that these six tragic deaths would not have occurred had these patients been treated adequately with anti-psychotic medication, the conclusion is inescapable that such deaths would have been less likely to have occurred. In my opinion, this is particularly evident in the cases of the deaths of Dr. Chandra, Mrs. Hogarth and Mrs. Ciampi, as in each of these cases the medication levels were minimal and were demonstrably inadequate to control psychosis in the patient.

Professor Goldney made it clear to me that, in his opinion, each of these six patients, all of whom had severe schizophrenic illnesses, should have been treated by qualified psychiatrists, or at the very least, by doctors who were being supervised on a regular and effective basis by a qualified psychiatrist. Matthew Proctor did not see a qualified psychiatrist in the fourteen months before he died. At the time of Peter Lewin’s death, Dr. Hustig told me that Glenside Hospital was suffering from an acute shortage of qualified consultant psychiatrists, although Mr. Lewin had seen a number of consultants in the last six months of his life. Bernard TenHoopen received treatment which could only be described as poorly-focussed and ineffective until such time as Dr. Gill reminded staff at Glenside that the fundamental diagnosis was one of schizophrenia, but even that failed to ensure that his treatment was adequately resumed. David Tzeegankoff had been treated by Dr. Chandra, who was a Career Medical Officer and not a psychiatrist, virtually since his first admission to Hillcrest Hospital in 1986. Professor Goldney was critical of the fact that he was not seen by a qualified psychiatrist on a more regular basis, a situation which he described as unfair on the non-specialist, and unfair on the patient who, with a severe illness, warranted the best treatment. He pointed to the fact that this problem was likely to increase in the push towards de-institutionalisation of psychiatric service towards community treatment models, thereby relating in a "dilution of a critical mass of expertise". In the case of Geoffrey Hogarth, I have already referred to the fact that Professor Goldney criticised the referral of responsibility by Glenside Hospital for Mr. Hogarth’s treatment to a general practitioner who was untrained in psychiatry. Frank Ciampi was also treated by a general practitioner, Dr. McKenna, in the last few months before the death of his mother, a fact which caused Professor Goldney "very serious concerns", concerns which were also held by Dr. McKenna herself.

In my opinion, the fact that many of the practitioners treating these patients were inadequately qualified should not result in a criticism of the practitioners themselves. As Professor Goldney commented, they were placed in an "invidious position" by a system which was unable to provide a sufficient number of qualified psychiatrists to cope with the caseloads involved. In my opinion, unless the situation can be addressed and improved considerably, such patients will continue to receive what Professor Goldney has described as inadequate treatment.

Perhaps as a concomitant to the inadequacies of the basic treatment approach taken in these cases, of the inadequacy of medications prescribed, and the lack of qualifications of treating personnel, Professor Goldney was also highly critical of the standard of record-keeping in relation to all of these cases, a criticism which was accepted by Dr. Hustig. In each of these cases, a mental state examination was not recorded with sufficient regularity, or at all, in order that a "longitudinal view" of the patient’s illness could be obtained by reading the casenotes. This has resulted in confusion about the basic diagnosis and inadequate regard being paid to the patient’s clinical history. He rejected any suggestion that such information was a counsel of perfection, describing it as "standard medical practice". In each case, the inadequacy of the record-keeping may also be a reflection of the inadequacy of the training and professional qualifications held by treating practitioners.

In particular, in my opinion the views expressed by Dr. Jha in the case of Geoffrey Hogarth about record-keeping are to be rejected, and Professor Goldney’s approach should be preferred, particularly in the case where the treating practitioner is not a qualified psychiatrist. In such a case, provided adequate notes are taken, it might be possible for a qualified psychiatrist who is supervising a practitioner to provide adequate guidance in the treatment of the patient, but not otherwise.

It is heartening to note the comments of both Dr. Rafalowicz and Dr. Hustig to the effect that this issue has been addressed. Hopefully, the issue has been addressed along with the other concerns I have outlined, which may have brought the problem about, namely lack of training, lack of experience, understaffing, and lack of supervision.

I also consider that Dr. Raeside’s evidence about the advantages which might flow from the computerisation of psychiatric casenotes should receive earnest consideration.

It is clear that there was insufficient communication between the family of the patient and their treating teams. In particular, David Tzeegankoff’s brother Alex was critical of the lack of such communication with Hillcrest Hospital, and the fact that, although he and his family were forced to deal with David while he was living at home, they were doing so without any information about his condition, whether his treatment had been changed in some way, whether to look out for particular symptoms, or whatever. It is also apparent that facilities which were available, namely the multi-disciplinary team operating from Port Adelaide, were not brought to the attention of the family. Similar concerns were raised by the family of Frank Ciampi.

It should be recognised that the families of people afflicted with these terrible illnesses need considerably more support than they were receiving in these cases. As Mrs. Hogarth’s daughter pointed out, families may feel a considerable degree of embarrassment and even guilt for the behaviour of such patients. On many occasions there is a reluctance to discuss such issues with health professionals, particularly when there is no confidence that any such concerns will be acted upon. Indeed, (name suppressed) made a number of very sensible recommendations which I adopt and repeat pursuant to Section 25(2) of the Coroners Act. Professor Goldney recognised that families are in a position to provide highly useful information to therapists about the behaviour of patients, and suggested that it ought to be possible to set up a scheme whereby a social worker, or other health professional, could be allocated the task of liaising with the patient’s family, and providing such information as is appropriate without breaching privacy or confidentiality provisions, while at the same time passing useful information back from the relatives to the treating doctors. Dr. Rose outlined a system adopted at Carramar Clinic, whereby families are given a contact point for any concerns they may wish to communicate, and that when a new patient is taken on, two people are nominated, one to see the patient and the other to liaise with the family, so that there is no breach of confidentiality or conflict of interest. I will recommend that such a scheme should be adopted more widely.

A number of issues concerning the security of staff in psychiatric institutions arose, particularly in the context of the deaths of Dr. Chandra and Mrs. Ciampi. While Dr. Rafalowicz told me that steps had been taken to remedy a number of security defects, and that such efforts were ongoing, I will make a recommendation that such issues should continue to receive close attention in view of the evidence of Dr. Rose that there are a number of outstanding issues to be addressed.

I have already referred to the fact that Professor Goldney told me that one of the results of de-institutionalisation of psychiatric services is the loss of a "critical mass of expertise" at major treatment centres in South Australia. Professor Goldney described this as a "dilemma" in that, on the one hand, resources are available to the patient in the local area, but that, on the other hand, this may result in loss of centres of real excellence. He said:-

"That’s one of the dangers that I think that we have run into in South Australia, with the breaking down of good institutions, that that critical mass of people has been lost. I think it is one of the reasons why psychiatrists have been leaving the system as well, because it is seen that that body of expertise is being diluted".

(T.761)

In another passage, he described how people with chronic illnesses become dependent upon institutions. Again, this constitutes a dilemma. He said:-

"The double-edged sword is that on one hand dependence is fostered, and all the bad parts of an institution can be invoked. The good thing is that people can view the institution as an asylum, a good old-fashioned asylum, as an area of expertise. If one person is not there, another will be available; if two people are not available there will be a third; there is a body of people who can take up the slack, whereas if you are in the community you might have four or five people in one centre, and if one or two are away you are really stretched".

(T.800)

He further explained his concept of a "good old-fashioned asylum":-

"And that gets back to the old idea of asylum, that when people are distressed there is a place for them to go. One of the dilemmas is now that there is a push to keep people out of hospital at all costs, and so the basic humanity of offering asylum to people has been lost".

(T.801)

Dr. Hustig agreed, explaining that at the time when Peter Lewin died, Glenside Hospital had lost such a large amount of expertise that they were unable to pursue accreditation as a psychiatric teaching hospital. He said that they did not pursue such accreditation because "we wouldn’t have achieved it". He explained that the situation has now improved somewhat, with support from the pharmaceutical industry, in that Glenside Hospital had become a centre of expertise in clozapine therapy (T.363).

Another effect of de-institutionalisation is the loss of availability of appropriately humane closed wards for the accommodation of psychotic patients. Kurrajong Ward at Glenside was described as "fairly spartan and prison-like", and more appropriate for a prisoner than a patient (T.366). Having regard to its design and staffing levels, staff were unable to keep illegal drugs out of Kurrajong. Accordingly, a facility for the placement of psychotic patients so that they could be free of illicit drugs, and so that their illnesses could be treated appropriately, was not available.

Since that time, Dr. Hustig explained that the situation has taken a turn for the worse, forcing the administration at Glenside to set up another temporary closed ward, which is "quite unsuitable" (T.367).

There can be no doubt that the lack of an appropriate closed ward facility has led to breakdowns in appropriate treatment for psychotic patients. There was a reluctance to utilise a closed ward environment when the condition of the patient clearly called for it. This also seems to have led to a reluctance to approach the Guardianship Board for detention orders in relation to psychotic patients, on the basis that closed wards really only "punish" the patient, in the words of Dr. Hustig (T.185).

Closed wards should, although secure, constitute a benign environment where treatment, and not punishment, is the priority. If such facilities were available, perhaps psychiatrists would be less reluctant to use them. Professor Goldney explained that with the decentralisation of mental health services, he was not sure that it was going to be possible to have secure areas in all community treatment centres. This emphasises the need for at least one excellent service where such a facility is available. He explained that "unless action is taken to make sure there is a secure area there, I think we could be in for further problems" (T.469).

I have already analysed the specific deficiencies in the psychiatric treatment provided to all six of the patients suffering severe mental illness in the cases before me. Each of those areas of deficiency should not be seen in isolation. They should be seen in the general context of the mental health system as a whole.

Each of these factors is, in my view, a symptom of a syndrome which Professor Goldney, quoting an English commentator, described as "malignant alienation" (T.444). He explained that this was a sense of hopelessness, as sometimes happens in a hospital when the morale goes down, when staff feel that they are powerless. This feeling then is transferred to the patients and, as with all malignancies, it grows. In Professor Goldney’s words:-

"Patients die, I think, because of it".

(T.444)

Clearly, such a syndrome is exacerbated by difficulties such as understaffing, underfunding, lack of training, and lack of cohesion in the organisation in which people work. This results in the staff, again to use Professor Goldney’s words, "losing sight of the ball". He said:-

"Then what can happen is that people tend to lose sight of the ball so to speak, tend to blame social factors, blame the administration without keeping your eyes on the ball, with the ball being the illness that these people have got".

(T.454)

Taking all the matters I have just described into account, I make the following recommendations pursuant to Section 25(2) of the Coroners Act, namely that the Minister of Health, those in charge of psychiatric institutions, the psychiatric profession, and those involved in provision of treatment and assistance to patients suffering from schizophrenia and related disorders, should be educated about, and reminded of the importance of the following factors:-

(1) the benefits of early diagnosis and treatment;

(2) the need to remain focussed upon the primary illness, and to provide effective treatment for it, rather than becoming preoccupied with the symptoms and effects of the illness, such as socio-economic factors;

(3) where coercive orders by the Guardianship Board are called for, the need for clear, accurate, up-to-date and helpful information to be provided to the Board;

(4) there should not be a reluctance to approach the Guardianship Board for such orders where the patient’s condition requires them, and that such action should be seen as therapy rather than punishment;

(5) where it can be reasonably anticipated that specialist opinion will assist in such an application, the services of a qualified psychiatrist should be available to assist in presentation of the case to the Guardianship Board;

(6) where the treatment of such a patient is to be in the hands of a general medical practitioner or Career Medical Officer, such a practitioner should receive supervision and assistance from a consultant psychiatrist so that strategic decisions concerning such issues as changes in medication, orders by the Guardianship Board, the need for detention, transfers between institutions, and the like are not made without specialist psychiatric input. The limits of the non-specialist practitioner’s role should be clearly defined and mutually understood;

(7) the level of medication used in the treatment of such patients should primarily be determined by the minimum levels required to control the patient’s symptoms, particularly psychosis. Of course, the side-effects of such medication should also be considered , and treated where possible, but should not deter aggressive attempts to treat the patient’s illness;

(8) medication should be given an adequate trial before being changed. During the trial, careful monitoring and accurate recording of the patient’s mental state should occur. Changes in medication dosages should only occur after a full analysis of these factors over an adequate period of time;

(9) the adequacy or appropriateness of particular types of medication should also be analysed carefully. If one form of medication does not prove effective, resort should be had to the other medications available, and an adequate trial should be undertaken before any conclusion is reached that the patient’s condition is not amenable to medication;

(10) the role of family members in the monitoring of a patient’s mental state for the purposes of paragraphs (8) and (9) should not be underestimated. They are often in a position to provide information which the patient is unable or unwilling to disclose, but which is highly relevant to a diagnosis or, for example, re-emerging psychosis;

(11) the standard of record-keeping should be sufficient to enable the assessments referred to in these recommendations to take place. In particular, regular and accurate recording of the patient’s mental state, including a note of the presence or absence of both positive and negative symptoms, should occur;

(12) consideration should be given to the computerisation of psychiatric casenotes to assist in this process;

(13) (name suppressed)’s recommendations, which I quoted in the findings in relation to Mrs. Gwenneth Hogarth, referred to the need for better communication between therapists and families, more support for families, better community education about mental illness, and better and more flexible and suitable non-institutional accommodation for patients. These are all extremely sensible and appropriate suggestions, and I adopt them for these purposes;

(14) the practice now adopted at Carramar Clinic, as described by Dr. Rose in the matter of Mrs. Consiglia Ciampi, whereby one member of the treatment team is specifically allocated the task of liaison with the family and supporters of the patient, should be considered for general application;

(15) the security of staff in psychiatric institutions should continue to receive close attention;

(16) the future planning of psychiatric services should take into account Professor Goldney’s views that at least one "centre of excellence" for the provision of psychiatric treatment should be retained, and that a facility should continue to exist where patients may seek asylum in such a centre in appropriate cases;

(17) the condition and ambience of closed words should be improved so that the detention of a patient in an appropriate case can be seen as humane and therapeutic, rather than as a punitive measure. At the same time, the security of such wards needs to be improved so that patients are prevented from having access to illicit drugs, thereby complicating their psychiatric condition;

(18) the fact that under-staffing, high staff turnover, lack of cohesive management, and under-funding can all result in the death of patients, when staff morale drops to the extent that a sense of hopelessness develops, described by Professor Goldney as "malignant alienation", should be recognised and addressed.

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Coroner

Inq.No.31/96