An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 25^th, 26^th and 27^th days of February, 11^th, 12^th and 19^th days of June, and 28th day of October, 1997, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Matthew Selwyn Proctor.

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 some stage during the afternoon of 28 March 1994 Matthew Proctor absconded from Glenside Hospital, and went to the house of Kylie Deane at 20 Malwa Street, Glandore. Matthew had been having a relationship with Ms. Deane for some weeks, although the nature of that relationship remains somewhat obscure. Ms. Deane also suffers from mental illness, and the only evidence I have concerning these events comes from a statement she gave to Senior Constable Thomas on 30 March 1994 at Glenside Hospital, where she had been admitted as an inpatient following Matthew Proctor’s death. Ms. Deane was clearly distressed by his death, and the symptoms of her illness are apparent from the record of interview, and so the reliability of this evidence is somewhat doubtful.

Ms. Deane said that Matthew Proctor had been at her house that afternoon, they had both consumed champagne that day, and he had told her that he had been smoking marijuana and had also consumed "speed" (Exhibit C.8c, p10). She said that Matthew had become upset because he was unable to get an erection, which he attributed to the medication he had been receiving (Dr. Goldney confirmed that the arousal of Matthew’s sexuality in the days preceding his death might well have been a significant factor in what subsequently occurred, although he agreed that this was speculative (see Exhibit C.26, p3).

Ms. Deane said that Matthew left her house at about 7.30p.m., telling her "I will see you tomorrow". He said that he was going to catch a tram, and then a bus to Glenside.

Mr. Proctor was seen by a staff member at Glenside standing near the casualty section at about 8.00p.m. that evening (see the report of Dr. Hustig, Exhibit C.25a, p3). No unusual behaviour was noted at that time. It is not known how, or why Matthew returned to Glenside, and then travelled back down to Bowden again, but in any event, at 9.32p.m. that evening the driver of a train approaching the Bowden Railway Station heading towards Adelaide from Outer Harbour saw a male person lying on the left-hand side of the track with his head on the rail at a point approximately half way between the railway crossing lights and the Bowden Railway Station. He said that this person was dressed all in black, his left cheek was on the rail and his head was facing the train. The driver said that he activated the horn and applied the full emergency brake of the train, but he was unable to avoid running over this person and causing him fatal injuries (see Exhibit C.4a).

At about 12.30a.m. the following morning, 29 March 1994, the identity of the deceased was established as Matthew Proctor.

At 8.35a.m. that morning, the cause of death was confirmed by the forensic pathologist, Dr. C.H. Manock, as "decapitation" (see Exhibit C.2a). A toxicology report prepared on 11 May 1994 confirmed that Matthew Proctor’s blood contained 11-nor-9-carboxy-THC (which indicates that he had consumed marijuana at some stage prior to his death). However, because neither alcohol nor THC (see Exhibit C.3a) were present, it is likely that Mr. Proctor was not under the influence of either alcohol or cannabis at the time of his death.

Matthew Proctor was first admitted to Glenside Hospital on 12 November 1990. He had a history of substance abuse involving marijuana and amphetamines. A tentative diagnosis of schizophreniform psychosis was made, although the crisis had apparently been precipitated by an overdose of both Melleril, an anxiolytic and neuroleptic medication, and Mersyndol, a codeine-based pain-killing medication. His psychosis settled spontaneously, which led to some uncertainty among the staff at Glenside as to whether he was suffering from schizophrenia at that stage (see the comments of Dr. Hustig, the Director of Extended Care at Glenside, at T.178), because substance abuse is an exclusion criterion for schizophrenia. In other words, the symptoms must be present in the absence of the effects of substance abuse, before the diagnosis of schizophrenia can be made with certainty.

Professor Goldney was critical of the fact that a clear diagnosis of schizophrenia was not made at that time. The evidence of increasing social withdrawal by Mr. Proctor for more than three years prior to his admission, accompanied by bizarre behaviour and auditory hallucinations, all suggested that he had been suffering from that illness for some time. However, Professor Goldney’s comments were tempered by his acceptance that, with concomitant drug abuse, there is always some doubt about the diagnosis (see his report, Exhibit C.26, p3).

Mr. Proctor was discharged from Glenside on 26 November 1990, his symptoms having settled spontaneously. He was re-admitted on 30 January 1991, having been referred by his general practitioner because of recurrent suicidal ideation. Dr. Hustig accepted that Mr. Proctor probably had schizoid personality disorder by that stage, and also questioned whether he was in the early, or "prodromal" stages of schizophrenia (T.179). He was discharged to the care of a private psychiatrist on 1 February 1991.

He was re-admitted to Glenside on 5 November 1991, and Dr. Hustig suggested that this admission may have been initiated by increasing stress due to impending court appearances on shop-lifting charges. His compliance with medication was noted to be poor, and he absconded from the hospital on several occasions. By this admission, a diagnosis of schizophrenia was accepted, although the situation was commonly complicated by cannabis abuse.

On 3 February 1992, orders were made by the Guardianship Board regarding Mr. Proctor’s custody and treatment, which effectively vested control of his accommodation and medication to the staff at Glenside Hospital. However, on 25 February 1992, the Board revoked the custody order.

Throughout 1992, a number of admissions and discharges to Glenside Hospital took place, and a common pattern developed whereby Mr. Proctor’s situation would improve with medication, and then become complicated because of marijuana abuse and absconding. Professor Goldney suggested that throughout this period, Mr. Proctor’s condition was never fully under control, and that his dose of Modecate (which he had been receiving since the treatment order had been made) could have been greater than 25mg every three weeks. In addition to Modecate (Fluphenazine Deconoate), Mr. Proctor was also receiving Haldol (Haloperidol Deconoate) and Pimazide.

During most of these admissions, it was noted that Mr. Proctor was described as "suicidal".

On 20 May 1992, Mr. Proctor was re-admitted to Glenside as a voluntary patient with a diagnosis of "chronic schizophrenia of a disorganised type". However, during that admission, it was agreed that his medication would be discontinued provided he agreed to undergo regular drug screens for substance abuse.

Dr. R. Thompkins, who was then a Registrar at Glenside, suggested that Mr. Proctor should spend six weeks in Brentwood, a closed ward, so that he could be free of drugs and so that "his uncontaminated mental state can be assessed, with a view to reviewing medication (and hopefully) inculcating some insight into the patient".

Professor Goldney records:-

"From my reading of the notes, this eminently sensible management plan does not appear to have been followed".

(see Exhibit C.26, p4)

 

 

Dr. Hustig explained that in his view there was no point in putting Mr. Proctor in a closed ward except to "punish him" (T.185). He also said that the Glenside staff realised Mr. Proctor would most probably appeal if they tried to impose such a programme upon him, and that they would not get support for such a proposal by the Mental Health Review Tribunal (T.188).

It therefore seems that Mr. Proctor’s treatment situation reached something of an impasse. Dr. Hustig acknowledged the possibility that Mr. Proctor was abusing drugs such as marijuana in an attempt to self-medicate (T.186), which is an indication that his illness was not under control, and yet that same drug abuse was interfering with their ability to treat his illness appropriately. Unfortunately, the records indicate that this dilemma was never really resolved.

On 16 June 1992, the Mental Health Review Tribunal revoked the detention order and Mr. Proctor was transferred to an open ward at the hospital.

Professor Goldney described this as an opportunity to treat Mr. Proctor which may have been lost. He suggested that Mr. Proctor had never really had the benefits of effective anti-psychotic medication (T.228), and he disagreed with the notion that an attempt to treat Mr. Proctor’s illness forcefully and effectively would simply alienate the patient, as suggested by Dr. Hustig. Professor Goldney said:-

"Yes, I mean that’s always a risk, but if one approaches it with the view that it’s done out of care and concern, and we have no other options because your life has been pretty awful so far and let’s give this a try - I think it can be presented in such a way that it is caring, other things have failed, so let’s give it a try. And more often than not, if there is an ounce of insight there, one can tap into that".

(T.230).

 

 

Having returned to the open ward, and the detention order having been revoked, Mr. Proctor continued to abuse marijuana, and was treated with intra-muscular Haloperidol.

On 17 July 1992 Mr. Proctor was discharged from Glenside. He re-presented the following day at the casualty section, but was not admitted. He was noted to be having "accommodation problems" by the casualty nurse. He presented again on 19 July 1992, when he was refused admission by the triage nurse. He presented again later in the day, where he was seen by Dr. Veale, but admission was effectively refused, since Mr. Proctor declined to be voluntarily admitted to a closed ward, submit himself to searches, and to generally cooperate with treatment.

On 20 July 1992 Mr. Proctor re-presented to Glenside, and on this occasion he was detained pursuant to the Mental Health Act by Dr. Kneebone. This resulted in a prolonged admission, with some periods of trial leave, until 13 December 1993. On 5 August 1992 the Guardianship Board granted a custody order in addition to the already current treatment order, and these orders were affirmed on appeal. This long admission was marked by several returns to closed wards, and by various attempts to treat him with medication, including the use of anti-depressant medication for the first time. During October, the use of Fluoxetine was considered, but was not proceeded with because a hospital protocol prevented its use. Dothiepin was used instead, and he remained on a dose of 150mg of that medication for the next two months. This was ceased on 31 December 1992 because of a lack of compliance. I will discuss this issue later, but at this stage it is sufficient to point out that Professor Goldney was of the view that Fluoxetine would have been a preferable medication in the circumstances, being much safer for suicidal patients, and usually had better compliance. In any event, Professor Goldney was critical of the fact that the dosage of Dothiepin did not go beyond 150mg a day, commenting:-

"Many patients with severe suicidal ideation and depression require higher doses of such anti-depressants".

 

 

On 29 October 1992, the dosage of Haldol was increased to 300mg every three weeks, and he remained on that dosage until 16 March 1993, when it was reduced to 150mg every two weeks because of side-effects.

In June of 1993, Dr. Hustig became involved as the consultant in charge of the team managing Mr. Proctor at Glenside Hospital (T.134). At that time, Dr. Hustig noted a diagnosis of schizophrenia had been made, and that other factors, including substance abuse, social chaos, and alienation from family and community, were complicating his situation (T.137). He told me that the treatment plan was to try and assess the minimum amount of anti-psychotic medication Mr. Proctor required, and to try and get him to change his pattern of substance abuse and life-style by providing more appropriate social support and a reasonable education about compliance and the role of drugs (T.138). He said that a treatment order was still in place, and that Mr. Proctor continued to receive Haldol at the rate of 150mg fortnightly. Additionally, he was receiving Benztropine (for the side-effects) and Valium (Diazepam).

In August 1993 Mr. Proctor was placed on "trial leave" at Mitchell Park Lodge, a licensed hostel. Dr. Hustig said that he received adequate supervision at that institution, and that the treatment orders were maintained. Mr. Proctor continued to receive his Haldol at the rate of 150mg per fortnight. He was performing work pursuant to a community service order at the rate of five hours per week, and was receiving follow-up from a social worker.

On 13 December 1993, the Glenside discharge summary commented:-

"Matthew was as well as he was ever going to be given his ongoing and unstoppable marijuana use".

(see the report of Professor Goldney at C.26, p5).

 

 

In January of 1994, Dr. Hustig became aware through information received from other patients and nursing staff that Mr. Proctor had been engaging in "high risk behaviour", in particular playing "chicken" with trains by standing on the railway line and jumping off at the last minute, and then daring other patients to do the same. Dr. Hustig commented that "there was concern at that particular time about whether we should be more restrictive to his behaviour or not", but no specific measures were taken since "the horse had bolted" (T.159-160). Mr. Proctor was still living at Mitchell Park Lodge at the time.

On 6 February 1994 Mr. Proctor presented to the casualty section at Glenside, and told Dr. Scurrah that he wanted to die, that "if I could get a gun I’d do it", and that he was "sick of this mental, physical and spiritual anguish". He was re-admitted as a voluntary patient and urine tests proved positive for the presence of both cannabinoids and benzodiazepines. Dr. Hustig described him as "quite cooperative with hospital admission procedures" (T.153), and for that reason he was not detained. He said that the social worker, Rachel Edwards, began to "address some of the social dilemmas he had got himself into" (T.152).

Dr. John Veale said that, in his opinion, given the problems of non-compliance with medication in the past, and his drug abuse, the intra-muscular medication had "reached as good a relief of symptoms as you are going to get but obviously wasn’t perfect" (T.287).

Despite Mr. Proctor’s apparent cooperation with admission, he absconded from Glenside on 8 February 1994 and returned to Mitchell Park Lodge, where he stayed for several weeks (see the evidence of Ms. Edwards at T.75). He was discharged from Glenside, although he continued to receive his periodic dose of Haldol.

Professor Goldney expressed surprise that his treatment, and in particular his level of medication, was not changed despite an apparent increase in his psychotic symptoms, in particular the presence of hallucinations on a number of different visits (see Exhibit C.26, p6). For example, Mr. Proctor presented at the Modecate Clinic at Glenside Hospital on 18 February 1994, and was noted to be complaining of hallucinations at that time. Later, on 11 March 1994, he was noted to be experiencing auditory hallucinations at the Modecate Clinic.

On 1 March 1994, it was established that Mr. Proctor was residing with a person named David Anderson in Claxton Street in the city. On 14 March 1994 he again presented at the casualty department at Glenside, complaining of restlessness and requesting Valium. He was expressing some concern about sexual dysfunction, and complained of auditory hallucinations telling him to kill himself. It was noted that he was quite dishevelled in appearance, his speech was quite rapid, and there were significant levels of Akathisia (restless leg syndrome). He was treated with Benzotropine (in order to deal with the side-effects as described), and allowed to leave. Dr. Hustig described this as "reasonable" (T.154).

On 17 March 1994 Mr. Proctor presented again to Glenside casualty department, where he was seen by Dr. Veale, who noted that he was expressing feelings of self-torment, hopelessness, and a wish to die. He said that he felt "pain in his soul". He had been living with his girlfriend, but the relationship did not work out, he was defaulting on his community service order, and faced further fines for marijuana possession, and was due to go to court on further charges. He had been evicted from the house in Claxton Street (see the evidence of Ms. Edwards at T.76), and had nowhere to live. He was admitted on a voluntary basis to Glenside Hospital on that occasion, and the Benztropine was gradually withdrawn.

Dr. Hustig expressed the view that, as Mr. Proctor’s psychosis was being kindled by substance abuse, there was no need to increase the level of Haldol medication (T.156). Dr. Veale said that he had been aware of Mr. Proctor’s earlier presentations on 11 and 14 March, and that the hallucinations were continuing when he saw him on 17 March. He said that Mr. Proctor was "no more suicidal than he had been on any other occasion" (T.292). He confirmed that Mr. Proctor’s accommodation difficulties were the main reason for his admission to hospital.

By 18 March 1994, Mr. Proctor was no longer expressing suicidal thoughts to Dr. Veale, but did express such thoughts to Ms. Edwards, the social worker.

On 25 March 1994 Mr. Proctor received his last injection of Haldol.

Mr. Proctor was last seen by Glenside staff at about 1.00p.m. on 28 March 1994 in Birch Ward.

Professor Goldney provided a comprehensive report concerning Matthew Proctor’s death, having examined a number of the statements which were tendered at the hearing, together with the three volumes of casenotes prepared at the Glenside Hospital, and included in which was Dr. Hustig’s report (Exhibit C.25a), somewhat unfortunately described as a "Death Audit". Professor Goldney was critical of a number of aspects of Mr. Proctor’s treatment at Glenside.

When he gave evidence, Dr. Hustig described Professor Goldney’s report as amounting to a "good resume of Mr. Proctor’s history and the dilemmas that arise in it" (T.162). However, Dr. Hustig disagreed with some of the criticisms made by Professor Goldney, saying that he "underscores the social factors, and tends to overstate the effectiveness of medication in dealing with these problems. He also doesn’t elucidate the vicious cycle . . . where you are trying to control their psychosis with increasing doses of neuroleptics, which in turn gets them to abuse the drugs even further in a way to combat the side-effects that they’re experiencing from the depot medications . . ." (T.163).

In general, Dr. Hustig stood by the comments he made in his report as follows:-

Matthew Proctor had a long history of suicidal ideation and all reasonable treatment strategies had been utilised;

in the days preceding his death, his management appears to have been appropriate and in accordance with managing him in the least restrictive environment;

his case highlights the difficulty in managing patients with a dual diagnosis of substance abuse and major psychosis, and the need for assertive community management in providing treatment to this very severely disabled population of those with chronic schizophrenia.

(Exhibit C.25a, p3-4).

1. Diagnosis of schizophrenia

I have already referred to the fact that Professor Goldney was critical of the fact that Mr. Proctor’s schizophrenic illness was not diagnosed during his first admission to Glenside in November 1990. He described it as "surprising". This is a particularly important issue because there is evidence that the earlier such a diagnosis is made, the more likely it is that treatment will be effective.

Professor Goldney said:-

"I think there is a reluctance to diagnose schizophrenia in young people because it’s considered by some - it sounds a bit dramatic, but it’s almost like a death sentence if a young person has got schizophrenia; whereas in fact it should be considered as an opportunity to intervene early".

(T.242)

 

As I have also mentioned, however, this criticism must be tempered by the fact that Professor Goldney accepted that when there is concomitant drug abuse, there is always some doubt about the diagnosis (Exhibit C.26, p3).

However, I record Professor Goldney’s comments in the hope that this issue might be addressed and more effective treatment for schizophrenia might result from an earlier regime of appropriate treatment. Hopefully, this may reduce the incidence of the complicating issues referred to by Dr. Hustig, including accommodation crisis, criminal offending and drug abuse, and suicide.

2. Basic treatment approach

Professor Goldney disagreed with Dr. Hustig’s basic approach to treatment of Mr. Proctor, in that it tended to concentrate on the social and economic issues such as accommodation, criminal offending, alcohol and substance abuse, rather than dealing with the issue of schizophrenia as the basic problem.

Dr. Hustig explained the basic approach taken to Mr. Proctor’s treatment, at the time he took over as the consultant in charge of the team managing him, as follows:-

"The plan was to try and assess what would be the minimum amount of anti-psychotic medication he required and to largely try and get him to change his pattern of substance abuse and his life-style by trying to provide more appropriate social supports to him and a reasonable education about the importance of compliance and the importance that these drugs played in his illness. . . . He had had increasing difficulties in gaining any sort of support from either family or the community to the point that he eventually had problems even in being accepted in basic boarding houses . . . In the end what actually was happening was that we had a very open door policy for him, that he could return to the hospital whenever he was in crisis or chaos, and then we would try and find him a new place of abode for him and then try and get him stable in the new accommodation and at the same time try and reduce the level of social chaos he managed to get into".

(T.138).

 

 

This approach was reflected in a casualty protocol dated 4 March 1994, which states:-

"He may be re-admitted directly to the Birches, if admission is required. Urine for a drug screen should be obtained".

 

The protocol forms part of the casenotes, Exhibit C.25.

This approach was criticised by Professor Goldney on the basis that Mr. Proctor’s schizophrenic illness had not been adequately controlled and that, in those circumstances, to concentrate on socio-economic factors was unlikely to produce benefits. He said:-

". . . I think at times it is unfair of the medical profession to expect social workers, or housing people, to deal with things when we haven’t properly addressed the illness, and that’s what I am critical of. You have to do all those other things as well, but I think at times there can be too much of a focus on accommodation . . . issues. I mean, if one looks at the last few pages of his notes, . . . the majority of it is related to social issues rather than to medical/psychiatric issues. There is no decent mental status examination, there’s no suggestion of manipulation of things. It’s all social, which is terrific, but I think in fact the medical profession are letting down our colleagues by not ensuring that you’ve had absolutely everything done from the straight biological psychiatry point of view".

(T.269)

 

 

I have already mentioned the fact that in May and June of 1992, Dr. Thompkins had proposed to keep Mr. Proctor in a closed ward for four to six weeks, so that he could be kept away from "non-prescribed medication", and so that his "uncontaminated mental state" could be assessed, and that Professor Goldney regarded this as an "eminently sensible management plan" (Exhibit C.26, p4).

Dr. Hustig said that this plan was not undertaken because there was "no point putting him in a closed ward except to punish him" (T.185), and that they knew that they would not receive support for such a proposal from the Mental Health Review Tribunal in the likely event that Mr. Proctor appealed against such a treatment regime (T.188). He also suggested that the use of closed wards carried with it a risk of alienating the patient, and that, in any event, they were unable to keep closed wards free of "non-prescription medication" since they had no right to engage in body-searching of patients (T.167).

Professor Goldney rejected these arguments, saying firstly that it is always possible to present such a proposal to the patient in such a way that the patient realises that it is for his own benefit if "there’s an ounce of insight there" (T.230), and secondly that the responsibility remained with the medical profession to present such information to regulatory bodies such as the Guardianship Board and the Mental Health Review Tribunal in a more thorough and rigorous way so that appropriate decisions are made for the benefit of the patient. He said:-

"Sometimes the legislation really prevents people getting access to treatment because of the civil liberties and it is a delicate balance; . . . I vacillate between the personal view that the system has swung too far, I think in fact it’s because we, as practitioners, don’t use the system properly. If we presented data to the tribunals in a more rigorous way, I think tribunals would be willing to accept what we had to say".

(T.263)

 

 

3. Medication

I have already referred to the fact that in February of 1994 Mr. Proctor had been receiving intra-muscular injections of Haldol in a dose of 150mg every two weeks. Indeed, his medication level had been as high as 300mg every three weeks in October of 1992, and was reduced in March of 1993 to 150mg every two weeks.

In February of 1994 there were a number of presentations to Glenside Hospital in which Mr. Proctor was displaying clear symptoms of psychosis, and he was frankly suicidal, and yet his medication regime remained the same. Dr. Veale explained this, saying that given his problems of non-compliance with medication, and his drug abuse, it was felt that the medication level had "reached as good a relief of symptoms as you were going to get, but obviously wasn’t perfect" (T.287).

Professor Goldney, however, was critical of the fact that the anti-psychotic medication was not adjusted when Mr. Proctor presented with these psychotic symptoms. He said that the trial of Haldol at 300mg every three weeks from October 1992 to March 1993 had been acceptably long, but suggested that, since it had proved unsuccessful in controlling his symptoms, some other medication should have been tried, perhaps Flupenthixol (T.248).

Professor Goldney said that there were other options available, including Chlozapine (although he conceded that this medication, while highly successful in some areas, also has serious side-effects and that in 1993 and 1994 it was still in its early stages of introduction), and even Lithium and/or electro-convulsive therapy (Exhibit C.26, p6-7).

Professor Goldney was also critical of the fact that there had been an inadequate trial of anti-depressant medication which had been introduced in 1992. Dothiepin had been prescribed in a dose of 150mg, which Professor Goldney described as inadequate (C.26, p7). Its discontinuance on the basis that Mr. Proctor was non-compliant (Dr. Hustig T.176) did not explain why he was not tried at a higher dose. This may have been more effective, and may have led to greater compliance. Alternative anti-depressant medication such as Fluoxetine, which had a better compliance rate, could have been tried.

I have already referred to the fact that a virtual "open door" policy had been adopted in relation to Mr. Proctor. It may be that this generous but fairly casual policy led to a lack of continuing attempts at rigorous analysis of his problem. Professor Goldney agreed with that proposition in the following passage of evidence:-

"Q. One gets an impression . . . that there was a familiarity with Mr. Proctor at Glenside by staff that didn’t lead to contempt at all, but that had at least to a degree categorised him, labelled him, as someone who was the author of his own misfortune by drug abuse, and that this attitude was under-pinned by a conviction among staff there, that the level of medication that he was on certainly controlled his disease, but for marijuana abuse. Is that a fair comment?

 

A. I share that view".

(T.256).

 

 

 

4. Qualifications of staff

Professor Goldney was critical of the fact that, during a period of about 14 months, from February 1993 to the time of Mr. Proctor’s death on 28 March 1994, there was not a single record of an attendance upon Mr. Proctor by a qualified psychiatrist. As he pointed out, Mr. Proctor had a very serious illness which can best be illustrated by the following passage of evidence, when the question of electro-convulsive therapy was being discussed:-

"Q. Dr. Hustig said yesterday, when dealing with patients who are unlikely to consent to it, he said the Guardianship Board would also be unlikely to consent to it unless it’s to be used against a life-threatening problem.

 

A. I am sure he is right, and Mr. Proctor had a life-threatening problem".

(T.249)

 

 

In those circumstances, Professor Goldney was critical of the fact that specialist medical treatment was not available to him. He said:-

". . . I am aware of the paucity of psychiatrists at Glenside, particularly at that time. But I just don’t think it’s good enough. If someone has a severe illness that is not responding, I think they deserve to be seen by a qualified psychiatrist. And to have not been seen - to have not had an assessment recorded for a period of 14 or 15 months is not good".

(T.245)

 

 

5. Quality of record keeping

It may be that this lack of treatment from a qualified psychiatrist led to what Professor Goldney suggested was the inadequate nature of the records of Mr. Proctor’s treatment in the Glenside Hospital casenotes (Exhibit C.25). The fact that the casenotes were confusing and difficult to follow was illustrated by the fact that Dr. Hustig himself had difficulty following them (see his evidence at T.151). Dr. Hustig said that there was a general guideline whereby observations should have been taken and recorded on "settled chronic inpatients" at least every second day. He agreed that this guideline was not complied with in the last week or so of Mr. Proctor’s life (T.194).

Professor Goldney also noted that, although Dr. Asz saw Mr. Proctor daily from 17 March to 28 March 1994 (see his statement Exhibit C.27a), there is no record of this contact in the casenotes. Indeed, he was generally critical of the fact that there was a general lack of recording of mental status examinations from which any form of longitudinal view could be obtained of the patient’s illness. This led, he suggested, to a tendency to try and re-diagnose the patient’s condition on each contact, without paying due regard to findings made by previous clinicians. He said:-

"And I have noticed, looking at some of these notes, that clinicians seem to be sceptical of what had previously been observed, and not to accept it; which seems to me to be odd. I mean if somebody . . . has recorded that Mr. Proctor said he experienced auditory hallucinations, why on earth should someone two years down the track think that wasn’t significant . . . It seems to be a rejection of previous observations, and that’s why I think it’s so important to have a mental status examination . . . because if you put down a mental status examination it’s a bit like taking the blood pressure, taking the pulse, it’s engraved in stone . . . and I think people are more likely to take notice of it".

(T.243)

 

 

As I have mentioned, Dr. Hustig accepted these criticisms.

I find that Matthew Selwyn Proctor, late of Glenside Hospital, aged 23 years, died at Bowden Railway Station on 28 March 1994 as a result of decapitation.

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.

 

 

……………………………..………