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REPORT TO THE NORTH EAST STRATEGIC HEALTH AUTHORITY OF THE INDEPENDENT INQUIRY INTO THE HEALTH CARE AND TREATMENT OF ANTHONY STEWART November 2008 2 CONTENTS Contents 1 Nature of the inquiry 4 2 Circumstances giving rise to the inquiry 6 3 Terms of reference 7 4 National Policy Framework 8 5 Contact between patient and psychiatric services 9 6 Contact between patient and psychiatric services in 2003 11 7 Commentary on contact between patient and psychiatric services 12 8 Discussion with Anthony Stewart 14 9 Evidence received at the inquiry 15 10 Written contribution by general practitioner 22 11 Findings 23 12 Recommendations 26 3 NATURE OF THE INQUIRY 1 Nature of the inquiry An inquiry into the heath care and treatment of Anthony Stewart with recommendations as to future practice. The inquiry panel was appointed by the North East Strategic Health Authority in January 2007 to enquire into the health care and treatment of Anthony Stewart. The members of the inquiry panel were: Mr Brian C Forster QC, Barrister A Crown Court Recorder and a President of the Mental Health Review Tribunal Dr P Quinn Consultant Forensic Psychiatrist, South West Yorkshire Mental Health NHS Trust, Regional Secure Unit, Newton Lodge, Wakefield Mr H Cronin Director of Nursing, Psychology and Allied Health Professionals, Tees Esk & Wear Valley NHS Trust The inquiry was established under the terms of the Health Service Guidance HSG(94)27 (as amended June 2005), following the conviction on 22 March 2005 at Newcastle upon Tyne Crown Court of Anthony Stewart for the manslaughter of Lee Carl Johnson and his subsequent sentence to detention in hospital without limit of time. The inquiry panel met between January 2007 and November 2007. The panel heard evidence from the individuals involved in the immediate treatment of Anthony Stewart and read substantial documents from the relevant agencies that had involvement with Anthony Stewart. All of the witnesses who gave evidence have had the opportunity to amend and approve the transcripts of their evidence. The object of the inquiry has been to investigate the events which gave rise to the death of Lee Johnson and to identify areas in which health care, treatment and practice could be improved. For this reason, and in order to encourage uninhibited contributions to the inquiry, the professionals who came into contact with Anthony Stewart are not identified by name. Furthermore insofar as is practicable, other individuals are not identified by name. This report has been prepared on the basis that all witnesses have provided full and frank disclosure to the inquiry panel. The inquiry panel would wish to express its gratitude to the Panel Co-ordinator, Mr Richard Smith, for his assistance in the administration of the inquiry. 4 NATURE OF THE INQUIRY Mr B C Forster QC (Chairman) Dr P Quinn Mr H Cronin 5 CIRCUMSTANCES GIVING RISE TO THE INQUIRY 2 Circumstances giving rise to the inquiry On the 28 August 2003 Anthony Stewart killed Lee Johnson. At the time of the killing Anthony Stewart, who was born on 2 April 1965, was 38 years of age and the victim was 29 years of age. He was a neighbour of Anthony Stewart and lived in the flat above him. Late in the evening other residents of the flats reported a disturbance. The emergency services attended. The victim was found to have been stabbed some seven times. Despite attempts to resuscitate him he was later pronounced dead. Anthony Stewart was initially charged with the offence of murder. Following the receipt of medical evidence, a plea to manslaughter on the ground of diminished responsibility was accepted. The judge stated that at the time of the killing Anthony Stewart was suffering from a delusional belief system. Unfortunately, many members of our community suffer from severe and enduring mental illness which can have a devastating impact upon the lives of those affected. At the time of the killing Anthony Stewart was suffering from a mental illness namely, paranoid schizophrenia. Anthony Stewart first came into contact with mental health services in Newcastle in May 1995. He was admitted to hospital on a number of occasions because of concern as to his mental health. In January 1999 Anthony Stewart was made subject to a probation order with a condition of medical treatment from a consultant psychiatrist. At the time of the killing Anthony Stewart was under the care of a consultant forensic psychiatrist. Anthony Stewart was an informal (voluntary) patient. He was not receiving treatment under any form of Order. Anthony Stewart had been discharged from the case work of the community psychiatric nurse (CPN) and approved social worker (ASW). 6 TERMS OF REFERENCE 3 Terms of reference To examine the circumstances of the surrounding health care and treatment of Anthony Stewart, in particular: • the quality and scope of his health care and treatment, in particular the assessment and management of risk; • the appropriateness of his treatment, care and supervision in relation to the implementation of the multi-disciplinary care programme approach and the assessment of risk in terms of harm to himself and others; • the standard of record keeping and communication between all interested parties; • the quality of the interface between the forensic and general mental health services and other agencies; • the extent to which his care corresponded with statutory obligations and relevant guidance from the Department of Health. To prepare a report of the findings of that examination for, and make recommendations to, the North East Strategic Health Authority. 7 NATIONAL POLICY FRAMEWORK 4 National Policy Framework The national care policy for the management of patients suffering from mental illness is the care programme approach which was revised in 2000 when a further policy was issued being the Effective Care Co-ordination in Mental Health Services – Modernising the Care Programme Approach (2000). Care programme approach The Care Programme Approach (CPA) was introduced in 1991 HC(90)23/LASSL(90)11 to provide a framework for effective mental health care. Its four main elements are: 1 systematic arrangements for assessing the health and social needs of people accepted into specialist mental health services; 2 the formation of a care plan which identifies the health and social care required from a variety of providers; 3 the appointment of a key worker to keep in close touch with the service user and to monitor and co-ordinate care; and 4 regularly review and, where necessary, agree changes to the care plan. Effective care co-ordination in mental health services – modernising the care programme approach (2000) In 2000 the CPA national policy was reviewed with a view to integrating the process with care management to form a single care co-ordinator approach for adults of working age with mental health problems. The review of the policy resulted in a number of recommendations including the following: • For two levels of CPA to be introduced; standard and enhanced. • That the supervision register should be abolished. • That the key worker would be known as the care co-ordinator. • That risk assessment and risk management were essential and ongoing elements of the CPA process that would include contingency plans in regard to risk assessment and management. The policy booklet stated that the requirement to maintain supervision registers would be abolished from 1 April 2001. However, before the Trust abolished its supervision register the offices of the then Regional Health Authorities must be satisfied that robust CPA arrangements are in place. The implementation of the national policies is the responsibility of the individual mental health trusts who should draw up their own local policy framework. 8 CONTACT BETWEEN PATIENT AND PSYCHIATRIC SERVICES 5 Contact between patient and psychiatric services Anthony Stewart first came to the attention of general adult services against the backdrop of serious mental illness (paranoid schizophrenia). He required admission to psychiatric hospital on 6 May 1995 under Section 2 Mental Health Act 1983 at a time when it was alleged he perpetrated an assault on a female neighbour. He was not subsequently charged. At that time he described a complex delusional system with a conspiratorial theme. He believed he was subject to a conspiracy orchestrated by the People’s Theatre, Tyne Tees Television, Newcastle City Council and an ex-director of Social Services. When discharged he did not agree to attend the general adult psychiatric outpatient clinic as part of his follow-up. Anthony Stewart’s first contact with forensic services occurred following a referral to local forensic services from general adult services for a second opinion. On 19 July 1995 he was seen by the consultant forensic psychiatrist (CFP), in the absence of a colleague, in an outpatient clinic. He was not co-operative during the course of that clinical interview. It was concluded by CFP that his presentation was compatible with a continuing paranoid psychosis into which he had no insight. He was detained under Section 3 Mental Health Act 1983 and admitted to hospital on 17 August 1995. He presented at his general practitioner’s surgery and again described delusional beliefs with a conspiratorial theme. He was discharged from hospital on 25 October 1995 and diagnosed as suffering from paranoid psychosis. In late 1996 he was non-compliant with treatment and began to disengage from members of the clinical team. His next contact with forensic psychiatric services arose following an allegation of assault. He was remanded into custody at Holme House, Stockton on Tees. On 11 November 1998 he was admitted onto Alnwick Ward into the care of CFP under Section 36 Mental Health Act 1983. On admission he was noted to have no insight. It was known to the clinical team that he had previously disengaged from treatment and after-care arrangements while in general adult services.

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