REPORT OF THE INDEPENDENT INQUIRY INTO THE CARE AND TREATMENT OF ALEXANDER CAMERON Commissioned by Berkshire Health Authority September 2000 PREFACE AND ACKNOWLEDGMENTS On 26 April 1997, Alexander Cameron killed his mother, Mrs Eileen Cameron. Mr Cameron was receiving out-patient treatment at the time, having been discharged from Fair Mile Hospital on 12 December 1994. He was admitted to a secure hospital in May 1997, and he remains detained there, having since been convicted of manslaughter on the grounds of diminished responsibility. There have already been two reviews of Mr Cameron’s care and treatment during the period before his mother’s death. One of these was an internal review undertaken by members of the NHS trust which manages Fair Mile. The other was undertaken by two external consultant psychiatrists. A third review, more than two years on, was a further source of distress for Mrs Cameron’s daughter, Julie Cameron. We therefore particularly wish to acknowledge the constructive and measured way in which she and her partner helped us. We also wish to acknowledge the way in which the professionals involved in Alexander Cameron’s care and treatment worked with us during what was a difficult time for them. Their candour, and commitment to providing the best possible service to local people, was commendable. Such candour is to be encouraged because it is the ultimate test of professionalism. The mature professional who accepts that their practice, or local practice, can be improved upon thereby ensures that the future direction of the service is based, not on falsehood, but on a true, comprehensive, understanding of its current state. We also commend the willingness of Berkshire Health Authority, the West Berkshire Priority Care Service NHS Trust, and the Reading Social Services, to work with us towards agreed conclusions and action plans. A constructive process is impossible without that commitment, but giving it, when many previous inquiries have been highly critical of individuals, took real courage. Lastly, but certainly not least, we wish to thank Mrs Lynda Winchcombe, our inquiry manager, for her exemplary management of the process. We have tried to conduct our inquiry more in the nature of a review. One directed at achieving consensus and the formulation of action plans designed to improve local services. Our report makes no reference to individual professionals: the value of such a review lies in identifying, and gaining support for, feasible improvements, not in apportioning blame. Mr Cameron, and not those who tried to help him, bears responsibility for his mother’s death, albeit that his responsibility was diminished. Some sections of this report duplicate sections of a report published in April 2000 concerning the care and treatment of Stephen Allum, who lived in Maidenhead. Two of the individuals who inquired into that tragedy were members of this review; and the overlap was necessary in order to ensure that services across Berkshire are developed according to a common standard. Our report is a short one. It concerns services provided to people in the Reading area and we wish it to be available to, and read by, both local people and professionals. With this in mind we hope that Berkshire Health Authority will ensure its wide dissemination to community groups, including libraries, community mental health services, voluntary and statutory housing organisations, Citizens Advice Bureau; and to police, probation and social services, in-patient psychiatric units and specialist services. i As a final, personal, note, I would like to emphasise that my own impression of psychiatric wards is 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 severe pain, most patients remain dignified and courteous, and somehow retain the compassion to respond to the plight of others in a similarly unfortunate situation. Anselm Eldergill (Chairperson) ii CONTENTS Chapter Title and contents Page Preface and acknowledgments i Contents iii Introduction v 1 How the inquiry was conducted 1 2 The national framework 7 3 The local framework 19 4 The human framework 31 5 Alexander Cameron’s care and treatment 35 6 Findings and action plans 45 7 Summary 75 iii iv INTRODUCTION During the early hours of 26 April 1997, Alexander Cameron killed his mother, Mrs Eileen Cameron, at their home in Reading. He later pleaded guilty to manslaughter on the grounds of diminished responsibility. The court ordered that he be detained in a secure hospital under the Mental Health Act 1983, subject to what is known as a restriction order. The effect of such an order is that his release from hospital requires the approval of the Home Secretary or a mental health review tribunal. WHY AN INDEPENDENT INQUIRY WAS NECESSARY National Health Service Guidelines issued in May 1994 require an ‘inquiry’ independent of the service providers when a person in contact with mental health services commits homicide. However, we prefer the term ‘review’ to ‘inquiry’, because it is more constructive. PURPOSE SERVED BY AN INQUIRY The function of an independent inquiry is thoroughly and objectively to review the patient’s 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 which may minimise the possibility of a recurrence of the tragic event. This is why the report is made to the bodies that have power to change the way the service is provided. The outcome should be that any feasible improvements are made, for the future good of everyone. Such inquiries serve important private and public needs. At a private level, individual tragedy requires a response, ideally determined by the individual circumstances: inquiries enable the bereaved to know that what happened is being fully and impartially investigated, and to be a party to that process. Equally, local people need to be reassured that the service is operating effectively. In such circumstances, it is wholly understandable, and wholly reasonable, that local people wish to be reassured that when family members come home, or friends or strangers return to their community, the risk of being seriously harmed is minimal. Although agencies outside the locality may draw useful lessons from an inquiry report, the cost and usefulness of the exercise does not require national justification. The value of the process lies in systematically examining the way in which a particular service, and group of professionals, operate and co-ordinate their efforts. WHO CONDUCTED THE INQUIRY The inquiry was undertaken by a panel of three professionals from outside Berkshire: Anselm Eldergill (Chairperson) Solicitor, Mental Health Act Commissioner, Member of the Law Society’s Mental Health Panel. Author of Mental Health Review Tribunals, Law and Practice. Dr Helen Kelly (Medical member) Consultant forensic pychiatrist. Dave Sheppard (Social work Co-Director of the Institute of Mental Health member) Law. Specialist trainer. Author of Learning The Lessons. v THE TERMS OF REFERENCE The terms of reference were drafted by Berkshire Health Authority. TERMS OF REFERENCE General remit 1. To examine the circumstances surrounding the treatment and care of Mr Alexander Cameron by the Mental Health Services and Social Services. In particular:— Assessments i. the quality and scope of his health, social care and risk assessments Treatment ii. the appropriateness of his treatment, care and supervision in and care respect of • his assessed health and social needs; • his assessed risk of potential harm to himself and others; • his history of prescribed medication and compliance with that medication; • his previous psychiatric history and treatment; • the number and nature of any previous court convictions. Compliance iii. the extent to which Mr Cameron’s care corresponded to statutory obligations, particularly the Mental Health Act 1983 and relevant other guidance from the Department of Health (Care Programme Approach (HC(90)23/LASSL(90)11) Supervision Registers (HSG(94)5); Discharge Guidance (HSG(94)27); and local operational policies. Care plans iv. the extent to which his care plans were effectively drawn up, delivered and complied with by Mr Cameron. Joint working 2. To examine the adequacy and style of the collaboration and communication within CMHTs, and between the agencies involved in the care of Mr Cameron or in the provision of services to him and his family. Training 3. To examine the appropriateness of the professional and in- service training of those involved in the care of Mr Cameron, or in the provision of services to him, and to consider any impact of ‘The New NHS’ white paper proposals. Report 4. To prepare a report and to make recommendations to the Berkshire Health Authority. vi 1 HOW THE INQUIRY WAS CONDUCTED ABOUT THIS CHAPTER This chapter summarises the way in which the review was conducted. It deals with the principles which underpinned it, the timetable, the procedures, and the information we received. OVERVIEW OF THE PROCESS The idea of a constructive, independent, review, which seeks to develop a partnership with the individuals and the services affected by the death, led us to adopt the following procedure: 1 Introductions Pre-review meetings were held with family members, Mr Cameron, and the teams, with the aim of allaying any fears they had about the process. 2 Documents As the documents were received, they were indexed and a chronology was prepared. 3 Induction An induction week was held, during which the panel visited relevant sites; received presentations concerning the organisation of services, and the local implementation of legislation and departmental guidelines; obtained independent perspectives from the Mental Health Act Commission, the Community Health Council, and local user groups; visited Mr Cameron, and spoke with his current treatment team.