Report of an Independent Review of the Care and Treatment of Mr Ogilpis Hamilton and Mr Abdul Rehman

Report of an Independent Review of the Care and Treatment of Mr Ogilpis Hamilton and Mr Abdul Rehman Commissioned by Birmingham & The Black Country Health Authority March 2004 FOREWORD We have independently reviewed the care and treatment of two people in north Birmingham who were convicted of manslaughter on the grounds of diminished responsibility. Our review was a further source of distress for the bereaved, and for the patients and their families. We particularly wish to acknowledge the way in which they helped us. We also wish to acknowledge the candour and commitment of the professionals who cared for the patients. A constructive process is impossible without openness, but being open, when so many inquiries have been critical of individuals, took courage. Such openness is to be encouraged, and is the ultimate test of professionalism. The mature professional who accepts that their practice, or local practice, can always be improved thereby ensures that the future direction of the service is based on a true understanding of its present state. The function of an independent inquiry is thoroughly and objectively to review the patients‘ care and treatment, in order to ensure that the services provided to persons with such needs are safe, effective and responsive. The purpose is to learn any lessons that may minimise the possibility of further tragedies. We make no reference to individual professionals: the value of such a process lies not in apportioning blame, but in identifying, and then gaining support for, feasible improvements to services. Given the complexity of the subject-matter, our report is relatively short. It concerns the services for people in north Birmingham and we wish it to be available to, and read by, local people and professionals. With this in mind we hope that the Health Authority will ensure that it is generally available, both in English and Urdu. As a final note, it needs to be emphasised that the enduring impression left after many years visiting psychiatric wards is for most people not one of fear or dangerousness, but of suffering and an often disarming kindness on the part of those who have lost their liberty. Although compelled to submit to the will of others, and forced to accept medication which may cause physical discomfort, most patients remain dignified and courteous, and retain the compassion to respond to the plight of others in a similarly unfortunate situation. Anselm Eldergill (Chairperson) Ian Blackie (Social work member) Claire Murdoch (Nursing member) Dr Stephen Wood (Medical member) i ii MAP OF BIRMINGHAM iii iv TABLE OF CHAPTERS Chapter Title and contents Page Foreword i Map iii Table of Chapters v Table of Contents vii 1 Introduction 1 2 The Human Framework 7 3 The National Framework 11 4 The Local Framework 21 5 Mr Hamilton‘s Care and Treatment 45 6 Mr Rehman‘s Care and Treatment 87 7 Summary and Recommendations 137 v vi TABLE OF CONTENTS FOREWORD I MAP OF BIRMINGHAM III TABLE OF CHAPTERS V TABLE OF CONTENTS VII 1 — INTRODUCTION 1 WHO CONDUCTED THE INQUIRY 1 PURPOSE SERVED BY THE INQUIRY 2 GUIDING PRINCIPLES 2 THE TERMS OF REFERENCE 3 OVERVIEW OF THE PROCESS 4 TIMETABLE 5 INFORMATION REVIEWED BY THE PANEL 5 PROCEDURAL SAFEGUARDS 5 2 — THE HUMAN FRAMEWORK 7 MENTAL DISORDER 7 RISKS ASSOCIATED WITH MENTAL DISORDERS 7 The risk of suicide 7 The risk of homicide and violence to others 7 Good practice and risk management 8 WHY NO SERVICE CAN EVER BE TOTALLY SAFE 8 3 — THE NATIONAL FRAMEWORK 11 MENTAL HEALTH ACT 1983 11 Applications for assessment under section 2 11 Emergency applications under section 4 11 Applications for treatment under section 3 12 Applications concerning care outside hospital 12 Relationship between the different applications 12 Short-term powers not exceeding 72 hours 13 Removal from a public place to a place of safety under section 136 13 Powers of criminal courts 13 Restriction orders 13 Powers of the Home Secretary 13 The use made of powers of detention 14 THE CODE OF PRACTICE 14 HEALTH SERVICE GUIDELINES 15 (a) Discharge of Patients from Hospital, Health Circular HC(89)5 15 (b) Local Authority Circular LAC(89)7 15 vii (c) Care programme approach, Health Circular HC(90)23 15 (d) Supervision registers, Health Service Guidelines HSG(94)5 16 (e) Guidance on Discharge, Health Service Guidelines HSG(94)27 16 (f) Introduction of the departmental after-care form (February 1995) 16 (g) Building Bridges document (November 1995) 17 (h) Modernising Mental Health Services (December 1998) 17 (i) Modernising the care programme approach (October 1999) 18 (j) National Service Framework (November 1999) 18 4 — THE LOCAL FRAMEWORK 21 1 — INTRODUCTION 21 A DIVERSE POPULATION 22 Census data 22 Age trends 23 Socio-economic position 23 Health inequalities 23 Issues for mental health services 23 SOCIAL-ECONOMIC DATA 24 Homelessness 25 HEALTH INDICATORS 25 Varied health 26 The Mental Illness Needs Index (MINI) 26 2 — OVERVIEW OF THE NHS IN BIRMINGHAM 27 BIRMINGHAM HEALTH AUTHORITY 27 The local adult mental health strategy 27 Health Improvement Programme 29 Management arrangements 29 Financial arrangements 29 Dissolution of Birmingham Health Authority 30 Birmingham & The Black Country Health Authority 30 STRATEGIC HEALTH AUTHORITIES 30 Contribution of Birmingham Health Authority 31 BIRMINGHAM’S PRIMARY CARE GROUPS AND TRUSTS 31 Establishment of primary care groups 31 Establishment of primary care trusts 31 Eastern Birmingham Primary Care Trust 32 PCTs and mental health 32 THE NORTHERN BIRMINGHAM MENTAL HEALTH NHS TRUST 33 Resources 34 BREAKDOWN OF TRUST STAFF AS AT 31 MARCH 2000 34 The North Birmingham model 34 A ‘functionalised’ model 35 The trust’s in-patient services 35 Bed numbers and occupancy levels 36 Intensive care 37 High dependency (special needs) beds 37 Rehabilitation services 37 Use of the 1983 Act 37 Community support services 38 Services for minority ethnic groups 38 Financial pressures 39 Management arrangements 40 Dissolution of the Northern Birmingham Mental Health NHS Trust 40 4 — BIRMINGHAM CITY COUNCIL 41 MENTAL HEALTH SERVICES 41 viii FINANCIAL ARRANGEMENTS 41 ASW ARRANGEMENTS 42 ASW PRACTICE 42 5 — MR HAMILTON’S CARE AND TREATMENT 45 MR HAMILTON’S CONTACT WITH SERVICES 45 The period from 1985 until 1999 47 MR HODGE’S CONTACT WITH SERVICES 51 MR HODGE’S DEATH 52 EVENTS FOLLOWING MR HAMILTON’S ARREST 54 FINDINGS 55 1 — THE INDEX OFFENCE 56 MR HAMILTON’S PERSONALITY 56 MR HAMILTON’S MENTAL STATE 57 THE ATTACK ON MR HODGE 59 2 — MENTAL HEALTH ACT ISSUES 59 WAS COMPULSION NECESSARY 60 The constitutional position 60 Was Mr Hamilton’s mental disorder of such a nature or degree? 60 Was detention justified for his own health or safety or to protect others? 61 The nature or degree of the disorder 65 ‘Degree’ 65 ‘Nature’ 65 Relapsing patients 66 The case for compulsion 66 Counter-arguments 68 CONCLUSIONS 70 3 — RISK MANAGEMENT 71 4 — CARE PROGRAMME APPROACH & AFTER-CARE 74 THE KEYWORKER ARRANGEMENTS 74 MEDICAL INPUT 74 Mr Hamilton’s consultant 75 THE CPA AND MR HODGE 75 UNDERLYING CAUSES 76 SUBSEQUENT PROGRESS 77 CPA Audit (December 2000) 77 5 — MULTI-DISCIPLINARY TEAM WORKING 78 UNDERLYING CAUSES 78 Organisational suspicion and hostility 79 High staff turnover 79 Different models and professional perspectives 79 Resource problems 80 Management of the Sutton Mental Health Team 81 SUBSEQUENT PROGRESS 82 6 — SUPERVISION ARRANGEMENTS 84 SUBSEQUENT DEVELOPMENTS 85 7 — SUPPORT FOR THE BEREAVED 85 8 — SUPPORT FOR MR HAMILTON 85 ix 6 — MR REHMAN’S CARE AND TREATMENT 86 MR REHMAN’S CHILDHOOD 87 THE PERIOD FROM 1974 TO 1989 87 FIRST ADMISSION TO HIGHCROFT HOSPITAL 89 SECOND ADMISSION TO HIGHCROFT HOSPITAL 89 THE PERIOD FROM MARCH 1991 TO JANUARY 2000 91 THIRD ADMISSION TO HIGHCROFT 92 The period at Highcroft Hospital 94 The period at Newbridge House 95 FINDINGS 96 1 — THE INDEX OFFENCE 97 2 — MENTAL HEALTH ACT ISSUES 98 THE SECTION 2 APPLICATION 98 The delay in effecting Mr Rehman’s admission 99 The decision to assess Mr Rehman without police assistance 99 Information sharing 101 THE SECTION 3 APPLICATION 101 3 — NEWBRIDGE HOUSE 102 YARDLEY/HODGE HILL HOME TREATMENT TEAM 102 Resource issues 103 Information sharing 104 PRESSURE ON BEDS 104 Consequences of the pressure on beds 105 The reasons for the pressure on beds 108 Bed pressures caused by inadequate community provision 108 Bed levels set too low 109 OTHER IN-PATIENT ISSUES 110 The in-patient staff mix 110 The in-patient nursing establishment 110 Nurse training 110 Security arrangements 111 Consultant staffing 112 4 — MR REHMAN’S TREATMENT OUTSIDE HOSPITAL 112 5 — mr rehman’s treatment in hospital 114 MEDICAL ASSESSMENT & TREATMENT 114 Obtaining previous medical notes 115 THE NURSING ASSESSMENT 115 THE DECISION TO AUTHORISE SECTION 17 LEAVE 116 THE DECISION TO ALLOW MR REHMAN LEAVE 117 6 — LOCAL community issues 119 LANGUAGE 119 CULTURE 122 STAFF RECRUITMENT 122 RESOURCE ISSUES 124 LOCAL STRATEGIES 125 Asian Services Directorate 125 Recent developments 126 7 — learning disability issueS 127 PEOPLE WITH MENTAL HEALTH PROBLEMS AND LEARNING DISABILITIES 127 LOCAL LEARNING DISABILITY SERVICES 128 LIAISON WITH MENTAL HEALTH SERVICES 129 x 8 — DOMESTIC VIOLENCE 130 REDUCING DOMESTIC VIOLENCE 133 9 — The trust’s OWN REVIew 134 CONDUCT OF THE REVIEW 134 DISCLOSURE OF THE REPORT 135 7 — SUMMARY, RECOMMENDATIONS, ACTION PLANS 136 WHO CONDUCTED THE REVIEW 137 PURPOSE SERVED BY THE REVIEW 138 PROCEDURAL SAFEGUARDS 138 TIMETABLE 138 INFORMATION REVIEWED BY THE PANEL 138 COMMENDATIONS 139 1 — FINDINGS CONCERNING MR OGILPIS HAMILTON 139

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