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 28^th day of October, 1997, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Bernard TenHoopen.

I, the said Coroner, do find that Bernard TenHoopen, late of 109 Blight Street, Renown Park, aged 20 years, died at the railway line, Brompton on the 28^th day of July, 1994 as a result of evisceration of the skull due to crush fracture of the skull.

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 7.00p.m. on 28 July 1994, Bernard TenHoopen, and two other patients of Glenside Hospital, David Forster and Andrew Kiltie, were drinking at an oval just off Fullarton Road near the hospital. Kiltie said that both Forster and TenHoopen were drunk, and that TenHoopen kept saying that he wanted to kill himself. When asked why, he said "Because I feel like it" (see Kiltie’s statement, Exhibit C.23c). Kiltie said that the group then took a taxi towards Port Adelaide for something to do. TenHoopen told the taxi to stop near the railway crossing on West Street at Brompton. They paid off the taxi, and Kiltie then saw TenHoopen walk over to the down-track of the railway line, and that he then said "See you later".

Kiltie said that he saw TenHoopen pull his beanie over his head, and then put his head on the railway track. He said that he and David Forster stood and watched as the westbound train ran over him. Andrew Kiltie then went to a nearby hotel and spoke to one of the patrons, who called the police.

This was confirmed by the train driver, who said that at 8.02p.m. on that day he was driving the train from Bowden Railway Station enroute to Croydon (towards Grange). The train had crossed East Street and was heading towards West Street when he saw a dark shadow adjacent to but on the outside of the left rail. He said that when the shadow came into the headlight beam he realised that it was a male person, but that the head was covered with a balaclava. He said that he applied the emergency brake of the train but, as he was still doing about 70 kilometres per hour, he was unable to avoid running over the person (see Exhibit C.21a, p1-2).

As a result of this event, Mr. TenHoopen sustained massive head injuries, and on 29 July 1994 the forensic pathologist, Dr. C.H. Manock, confirmed that the cause of death was "evisceration of skull due to crush fracture of the skull" (see Exhibit C.19a). A later toxicological analysis established that, at the time of his death, Mr. TenHoopen’s blood alcohol concentration was .204% (see Exhibit C.20a).

Bernard TenHoopen first came to the notice of the South Australian Mental Health Service on 4 December 1992 when he was detained pursuant to the Mental Health Act while he was a prisoner at Yatala Labour Prison. The effect of this detention was a transfer to James Nash House, a secure facility on the campus of Hillcrest Hospital. The detention was ordered because he had attempted suicide by lacerating his cubital fossa (inside of the elbow). Acute depression was diagnosed.

Upon arrival at James Nash House, a diagnosis of psychosis was made, which was later established as due to schizophrenia. His presentation had paranoid features, including waking up with complaints of bumps and itchiness on his head, and allegations that his cellmate had been putting pins in his head. He was suffering auditory hallucinations in the form of hearing voices, which Dr. Hustig described as a "clear picture of schizophrenia" (T.390).

Mr. TenHoopen was commenced on intramuscular Modecate injections in a dose of 37.5mg every three weeks, together with Benztropine for the side-effects. While at James Nash House, he was treated by Dr. S. Gill, a consultant psychiatrist, who noted on 4 February 1993 that the Modecate had brought about a marked improvement in his condition, and in particular that the auditory hallucinations had ceased (see the casenotes, Exhibit C.33).

On 1 March 1993, Mr. TenHoopen was discharged from James Nash House to Glenside Hospital. Custody and treatment orders made by the Guardianship Board on 8 January 1993 remained in force. The discharge summary from James Nash House dated 2 March 1993 and signed by Dr. Craig Raeside, who was then a psychiatry registrar, clearly stated that his diagnosis was schizophrenia, and that the mental state examination elicited clear evidence that he was psychotic.

Upon admission to Glenside Hospital, Mr. TenHoopen was placed in North Glen Ward for three months in the rehabilitation programme. He was commenced on a dose of 37.5mg of Modecate every two weeks, but this was reduced on 21 March 1993 to 25mg every three weeks, and again on 12 May 1993 to 12.5mg every three weeks. During this period, he was also receiving oral doses of Chlomazepam as required.

On 12 July 1993 the intramuscular Modecate was discontinued altogether. Dr. Hustig commented that any positive effects from the medication was doubtful given his marijuana use (T.397).

Mr. TenHoopen’s condition was monitored in case psychotic symptoms re-emerged. On 2 August 1993 aggressive and destructive behaviour towards other patients and staff was noted by the nurses.

On 27 August 1993 Mr. TenHoopen was released on trial leave to Mitchell Park Lodge, a licensed hostel where he would have received minimal supervision, without medication.

On 26 October 1993 Mr. TenHoopen was seen by Dr. J. Veale, a Career Medical Officer with long experience in, but no formal qualifications in psychiatry, in the outpatients department. Dr. Veale noted that no signs of his illness had re-emerged. On 2 November 1993 he was discharged from Glenside Hospital. At that time, Dr. Veale commented that his schizophrenia was "in remission", a conclusion with which Professor Goldney agreed (T.488). Professor Goldney said that this was a significant event, because when his illness relapsed, the fact that they were able to bring it under control at this time demonstrated that his illness would respond to vigorous treatment.

On 28 March 1994, Matthew Proctor died at the Bowden Railway Station. It was known to the staff at Glenside Hospital that Mr. TenHoopen and Mr. Proctor were close friends. The social worker at Glenside, Ms. R. Edwards, said that Mr. TenHoopen would frequently come to the hospital in order to speak to her about his feelings after Matthew Proctor’s death. She gained the clear impression that it had caused quite a serious deterioration in his mental state (see her statement, Exhibit C.24, p12).

On 4 April 1994 Mr. TenHoopen presented at the casualty department and was seen by Dr. M. Drennan, a Career Medical Officer. Dr. Drennan noted that he had been hearing voices, he was feeling suicidal, and he had injected himself with Lithium after having dissolved some tablets. He had been examined at the Royal Adelaide Hospital and was found to be alright. He was admitted as a voluntary patient to Glenside. However, he was released next day on two days’ trial leave (see Dr. Hustig’s evidence at T.402).

On 8 April 1994 Mr. TenHoopen returned for review and received counselling (T.402). On 9 May 1994 he presented at the casualty department and was seen by Dr. Frost. It was noted that he had been hearing voices telling him to kill himself, and that he had been evicted from his accommodation. He was referred to the social worker, and not admitted. It is not clear whether anything was done about his accommodation situation. He was assessed by the duty nurse as being of "low danger to himself or others", and was assessed by Dr. Frost as "not obviously psychotic and not suicidal" (T.404). This finding seems odd in view of Mr. TenHoopen’s presentation. Dr. Frost did not make a note of a detailed mental state examination on that occasion.

On 12 May 1994 Mr. TenHoopen presented again and was seen by Dr. Asz, who commented:-

"Coping well at the hostel and did not appear to be expressing any perceptual dysfunction or thought disorder".

(see Exhibit C.28a, p2)

 

Again, Dr. Asz did not make a note of a detailed mental state examination on that occasion.

On 19 May 1994, Peter Lewin died at near the Alberton Railway Station. There is no evidence that Mr. TenHoopen knew Mr. Lewin particularly well, nor is there any evidence that Mr. Lewin’s death had any effect upon his mental state.

On 21 May 1994 Mr. TenHoopen presented at the casualty department and was seen by Dr. Kent, who was then a Psychiatric Registrar. He complained of auditory hallucinations, and also of having been bitten by a spider at his accommodation, expressing an unwillingness to return. She noted that he had been abusing both amphetamines and cannabis. He referred to Matthew Proctor’s death. Dr. Kent found his symptoms "vague" and "unconvincing", and she referred him to St.Vincent de Paul’s in relation to his accommodation (see the casenotes, Exhibit C.31).

Dr. Hustig commented:-

"I think that on that presentation it’s a bit unfair dumping it back on St.Vincent de Paul, and probably would have been better to have chosen to admit him for assessment".

(T.402)

 

 

On 22 May 1994 Mr. TenHoopen presented again at the casualty department, and the casenotes record that he was seen by Dr. Kent. However, there is no note made by her referring to this attendance. He had been referred to Glenside by the Royal Adelaide Hospital, where he had earlier attended seeking medication for spider bites, saying that he had slept out in the open the night before. This reference to spider bites seems to have been a recurrence of an earlier symptom displayed at James Nash House when he was psychotic. However, notwithstanding this evidence, he was not admitted on this occasion either.

On 28 May 1994 Mr. TenHoopen again presented at the casualty department at Glenside Hospital, and was seen by Dr. Drennan. Again he was complaining of spiders crawling all over him, indeed he had shaved part of his hair to get rid of the spiders. He also said that he was hearing voices, although Dr. Drennan recorded that he seemed amused at his hallucinations, and that he was not acting on them. She interpreted this as "admission-seeking behaviour, not appropriate for admission".

The two social workers at the hospital, Ms. Edwards and Ms. McLeay, were concerned about this series of events. Ms. Edwards told me that Ms. McLeay discussed it with the casualty nursing staff, and that she reported that the nurses believed that Mr. TenHoopen had behavioural problems, personality problems, that they rarely believed that he had a mental illness. Ms. Edwards commented:-

"Sometimes the nurses can become more institutionalist than the patients".

(T.129)

 

Dr. Hustig conceded that "it would have been better to admit him" (T.406). He commented:-

"I would assume these days that an ACIS team would certainly find some accommodation for him and not leave him to his own devices to find the accommodation and that there would be some sort of follow-up . . .".

 

 

On 31 May 1994 Mr. TenHoopen again presented to the casualty department at Glenside Hospital, and was seen by Dr. Kent. She noted that his auditory hallucinations were making him feel suicidal, although he was not so pre-occupied with Matthew Proctor’s death, nor did he seem so pre-occupied with spiders. He was feeling aggressive towards other people, and she noticed a depressed affect. Mr. TenHoopen was admitted to hospital on this occasion, although the purpose of the admission was noted to have been "for respite and to sort out accommodation".

On 3 June 1994, Mr. TenHoopen was seen by Dr. Fiori. He was complaining of auditory hallucinations, restlessness and agitation, and extra-pyramidal side-effects from neuroleptic medication (which seems doubtful since he was not receiving any such medication). Dr. Fiori assessed his condition as consisting of an adjustment disorder with depressed mood in the context of a chaotic family background, poly-substance abuse and extra-pyramidal side-effects due to neuroleptic medication. Dr. Hustig conceded that schizophrenia should have been included in the differential diagnosis at that stage (T.411). He commented that Dr. Fiori may have become pre-occupied with the "organic side of Mr. TenHoopen’s presentations, particularly in terms of both the olfactory and tactile hallucinations" (T.411).

On 9 June 1994, Mr. TenHoopen was seen again by Dr. Fiori, and she noted some improvement in his condition. He was still not receiving anti-psychotic medication at this stage, although he was still hearing voices (see the evidence of Dr. Hustig at T.412). Dr. Fiori noted "no signs of delusions or hallucinations today" (which again seems to be an odd conclusion in view of his presentation).

On 15 June 1994 Mr. TenHoopen was seen by a psychiatric registrar complaining of headache. However, he was also displaying signs of increasing agitation, including leg spasms and auditory hallucinations. He absconded from Glenside Hospital at some stage that afternoon. He was detained pursuant to the Mental Health Act by the local general practitioner in Murray Bridge the following day. He had gone to that doctor seeking medical treatment. On return to Glenside he was noted to have been extremely agitated, showing signs of tachycardia (fast heart rate) and hyperventilation. He was reviewed firstly at the Royal Adelaide Hospital and then returned to Glenside, where the detention order was confirmed. There seems to have been considerable diagnostic confusion as to whether he was suffering from delirium, schizophrenia or personality disorder. He was placed on a Benzodiazepine withdrawal regime on the basis that he may have been suffering a drug-induced psychosis.

On 20 June 1994, Mr. TenHoopen was seen by Dr. Fiori and he told her that he had been taking Phenergan tablets (up to six to eight tablets a day). Phenergan is an anti-histamine medication, and he explained to her that he was taking it to "help him control the spiders". She noted that although he was demonstrating frank symptoms of auditory and tactile hallucinations, she did not think he was thought-disordered. She regarded the diagnosis as "not clear".

Dr. Fiori arranged for Mr. TenHoopen to be reviewed by Dr. Shane Gill, the consultant psychiatrist who was acting in Dr. Hustig’s place as the Director of Extended Care while Dr. Hustig was overseas. Dr. Gill recalled Mr. TenHoopen’s stay at James Nash House, pointing to his history of paranoid delusions and auditory and somatic delusions. He also reminded Glenside staff that this condition had responded positively to anti-psychotic medication, to the extent that by the time he was transferred to Glenside Hospital, his schizophrenia was no longer obvious. Dr. Gill ruled out alcohol or drug-induced psychosis, and said that Mr. TenHoopen’s condition was due to a recurrence of his schizophrenia, although he recognised that a personality disorder and substance abuse were complicating factors (see the casenotes, Exhibit C.31).

Mr. TenHoopen was prescribed Chlorpromazine as an anti-psychotic medication and Valium (Diazepam).

Dr. Hustig conceded that at this point it would probably have been appropriate for them to have applied to the Guardianship Board for an ongoing detention order, and to have recommenced Mr. TenHoopen on intramuscular Modecate (since this had been so clearly successful while he was at James Nash House in 1993). He said:-

"I think at this stage we were pre-occupied with his substance abuse. I accept that it was probably in hindsight something we should have done".

(T.343)

 

 

Dr. Hustig pointed out that he did not return from overseas until 27 June 1994, and that there had been a variety of consultants filling in for him during his absence. He indicated that this may have been the reason why there was some confusion about Mr. TenHoopen’s diagnosis prior to Dr. Gill becoming involved.

On 29 June 1994, Mr. TenHoopen absconded from Glenside again. While away from the hospital he consumed alcohol to excess, and upon his return to hospital later that afternoon displayed signs of agitation, smashing a mirror and causing some injury to himself. He continued to complain of visual hallucinations about dogs and spiders, and of tactile hallucinations about spider bites. He was transferred to a closed ward because of his aggressive behaviour and the fact that he appeared to be a suicide risk. He was described as "withdrawn and isolative, sullen and belligerent" (see the report of Dr. Hustig, Exhibit C.34, p2).

It would appear that Mr. TenHoopen remained psychotic for most of July, being transferred to Kurrajong Ward on several occasions because of increasing concerns about his suicidal ideation and depressed mood. He absconded again on 11 July and again on 19 July 1994. Ms. Edwards said that during this period he would approach her virtually on a daily basis, wanting to tell her about how he had been in touch with Matthew Proctor, and seeking information about his death (T.12). She was extremely concerned about his condition, and spoke to Dr. Asz and Dr. Hustig and "anyone who would listen" (T.121).

On 22 July 1994 Mr. TenHoopen returned to Glenside, and was seen by Dr. Asz. He returned to Kurrajong Ward as a voluntary patient and was commenced again on anti-psychotic and anti-depressant medication. However, two days later he was transferred to an open ward because, according to Dr. Hustig, this provided a "more active treatment programme in relation to his depression and grief" (T.418).

The detention order expired on about 25 July 1994. Ms. Edwards said that she pleaded with Doctors Hustig and Asz to seek a further detention order so that Mr. TenHoopen could be kept in Kurrajong Ward because she had concerns that he would kill himself (T.122). She admitted that she had no objective evidence to support this contention. She said that the doctors responded that they had no grounds to detain Mr. TenHoopen further.

Dr. Hustig explained that, although he sympathised with Ms. Edwards’ position, he did not feel that they had sufficient grounds to detain Mr. TenHoopen, and they did not think that they would get support from the Guardianship Board (T.420). Although he accepted that he thought Mr. TenHoopen was likely to do something "rash", he thought he was more likely to become intoxicated rather than commit suicide (T.420). I will deal with this issue again later.

On 26 July 1994 Mr. TenHoopen underwent grief counselling from a social worker retained specifically for the purpose, Mr. Alan Knott. Professor Goldney was critical of this approach, saying that in his opinion such counselling would have been of little use to Mr. TenHoopen since he was still psychotic at the time. I will also discuss this issue later in these findings.

Professor Goldney prepared a report into the death of Bernard TenHoopen, and in the process examined a copy of Dr. Hustig’s report (C.34), the statements which were tendered in evidence at the inquest, together with the Glenside Hospital casenotes (Professor Goldney had access to Volume 2, part of Exhibit C.31, although he did not see Volume 1 of the Glenside notes, nor the James Nash House casenotes (Exhibit C.33), until after preparing his report, but before he gave evidence).

Dr. Hustig acknowledged Professor Goldney’s report, describing it as:-

"In its entirety it’s a fair assessment of the situation and dilemmas we were trying to grapple with".

(T.421)

 

He added:-

"I think that to say we had complete control of his illness would be far from the truth".

(T.425)

 

 

1. Diagnosis of schizophrenia

I have already outlined the fact that Mr. TenHoopen’s diagnosis of schizophrenia was well-established at James Nash House and was accepted upon his first admission to Glenside Hospital on 1 March 1993. Indeed, when Mr. TenHoopen was discharged following his first admission to Glenside on 2 November 1993, he was described as having schizophrenia in remission (see the evidence of Dr. Veale at T.296).

However, during 1994, the significance of this diagnosis seems to have receded to the background, to the extent that his problems of substance abuse, poverty and "marked psycho-social stresses" took precedence. As Dr. Hustig said, those treating Mr. TenHoopen became "pre-occupied with the organic side of these presentations . . ." (T.411).

I have also pointed out that it was not until 20 June 1994, when Dr. Gill saw Mr. TenHoopen and was able to refer back to his knowledge of him at James Nash House, that treatment for schizophrenia was resumed with an appropriate course of anti-psychotic medication. It is of great concern that Mr. TenHoopen presented on numerous occasions in May and June of 1994 to Glenside Hospital seeking treatment, but did not receive it, his presentations being categorised at the time as "admission-seeking behaviour" (see the evidence of Dr. Hustig at T.405).

2. Basic treatment approach

I have already referred to the fact that Dr. Hustig accepted that Glenside staff did not have complete control of Mr. TenHoopen’s illness, even after 20 June 1994 when Dr. Gill reminded them that his basic problem was schizophrenia. Professor Goldney suggested that a much more aggressive approach to Mr. TenHoopen’s treatment should have been taken. He said:-

"In clinical psychiatric practice not infrequently schizophrenic illnesses take a number of weeks, and at times months, to respond adequately to therapeutic doses of anti-psychotic/major tranquilliser medication. When compliance is a problem, the limitations of a 21-day detention order become only too obvious. In Mr. TenHoopen’s case, with a history of absconding and non-compliance with medication, along with continuing psychotic symptoms, I consider that it would have been appropriate for him to have been placed on a continuing detention order to allow better control of his schizophrenic illness and suicidal ideation".

(Exhibit C.36, p10)

 

 

Ms. Edwards, the social worker, was, in her words, pleading with Dr. Hustig and Dr. Asz to detain Mr. TenHoopen further, but Dr. Hustig did not feel that they had sufficient grounds to do so (see his evidence at T.420). In response to Dr. Hustig’s suggestion that he did not think that they would get support from the Guardianship Board for such an approach, Professor Goldney replied:-

"I think that some of these (arguments) are rationalisations. . . . If one gave that longitudinal view (that the patient required continuing detention) to the Guardianship Board, I think it would be an unusual sort of Board who would deny the request for continuing admission or continuing medication. And I think in some ways the Guardianship Board are at a disadvantage. Perhaps they have been criticised when in fact they haven’t had the opportunity to make decisions . . . I think it gets down to the provision of adequate information".

(T.497-8)

 

 

Of course, the ability to provide a "longitudinal view" to the Board also depends upon proper and adequate record-keeping, a matter I will deal with shortly.

Professor Goldney also queried the usefulness of providing grief counselling to Mr. TenHoopen at a time when he was still psychotic. He said:-

"Unless one has control of delusional thinking and hallucinations, one is not in a position to undertake grief or other types of psycho-therapy with a patient".

(Exhibit C.36, p10)

 

 

Dr. Hustig joined issue with that comment, saying:-

"There is quite a bit of work now being done, particularly in the U.K., with cognitive therapy with patients who are actively hallucinating, as a way to actually reduce their hallucinations",

He conceded, however, that such counselling was far from ideal (T.436).

Professor Goldney tempered his criticism somewhat when giving oral evidence, accepting that, so long as such counselling was accompanied by a vigorous attempt to treat the psychotic illness, it was appropriate, depending upon the extent to which the patient remained thought-disordered (T.494).

3. Medication

A common theme throughout all of these cases has been a criticism by Professor Goldney of the inadequacy of the medication prescribed for sufferers of psychotic illness. This criticism was made in relation to Mr. TenHoopen’s treatment as well. Professor Goldney said:-

"Mr. TenHoopen did not have a satisfactory trial of anti-psychotic/major tranquilliser medication during his admission to Glenside Hospital".

(Exhibit C.36, p9)

 

 

He said that the dosages of both Chlorpromazine and Haloperidol were inadequate, even taking into account the fact that these drugs were supplemented with Valium (Diazepam). He said that the inadequacy of treatment was particularly apparent in the last few days of Mr. TenHoopen’s life, when he was taken off Haloperidol and another drug was substituted. He said:-

"In terms of equivalent anti-psychotic affect, the Pericyazine in which he was taking the last few days of his life would have been less effective than the previously noted doses of Haloperidol or Chlorpromazine. When one considers that he had also been taken off the Diazepam (Valium) three days before his death, and that he was also on the anti-depressant, Paroxetine, which has been reported to cause anxiety and agitation in some persons, it is quite evident that Mr. TenHoopen’s condition could not be considered to have been under control in the few days leading up to his death. . . . In view of the lack of compliance with regard to medication I consider that he should have been given the potential benefit of intramuscular medication, either Fluphenazine (Modecate), Haloperidol (Haldol) or Flupenthixol (Depixol). I cannot understand why that was not seriously entertained in view of the documented lack of compliance and history of absconding".

(Exhibit C.36, p9-10)

 

 

As I have already recorded, Professor Goldney pointed out that the success of vigorous and sustained course of medication achieved when Mr. TenHoopen was at James Nash House should have given optimism that with vigorous treatment, his symptoms could have been brought under control (T.488). It is a great pity that the staff at Glenside Hospital did not recognise the significance of those events when treating him in 1994.

4. Qualifications of staff

I have already referred to the fact that Mr. TenHoopen’s symptoms went largely unrecognised and therefore untreated during May of 1994, until he was admitted on 31 May 1994 by Dr. Kent. Dr. Kent was a psychiatric registrar in the final stages of her training at the hospital at that time.

I have also recorded the fact that it was not until Dr. Gill came into the picture on 20 June 1994 that the significance of Mr. TenHoopen’s schizophrenic illness was emphasised. Dr. Gill was an experienced consultant psychiatrist, and was able to draw on his knowledge of Mr. TenHoopen from an earlier period at James Nash House. Dr. Gill was acting as a replacement for Dr. Hustig, who was overseas until 27 June 1994.

Dr. Hustig accepted that many of the deficiencies in Mr. TenHoopen’s treatment during that period were the consequence of a lack of availability of senior consultant psychiatrists at that time (T.433).

5. Quality of record-keeping

Following on from the previous heading, I am sure it is no coincidence that during the same period, the quality of the note-keeping in the Glenside Hospital notes was also sub-standard. On several occasions when giving evidence, Dr. Hustig had great difficulty both in locating and interpreting notes made by hospital staff for that period. At one stage he said:-

"I am in huge difficulty".

(T.410).

 

 

Although this issue was not specifically addressed in relation to Mr. TenHoopen’s death, Dr. Hustig’s acceptance of these criticisms, and his indications of remedial action being taken at Glenside (discussed during the hearing into the death of Peter Lewin), are equally apposite to this case.

I find that Bernard James TenHoopen, late of 109 Blight Street, Renown Park, aged 20 years, died at the railway line, Brompton on 28 July 1994 as a result of evisceration of the skull due to crush fracture of the skull.

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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