Independent Inquiry into the Care and Treatment of Peter Bryan Part One A report for NHS London September 2009 Panel members Jane Mishcon was appointed as Chair of the Inquiry. She is a barrister at Hailsham Chambers whose main area of practice is clinical negligence. She has chaired nine inquiries following homicides committed by psychiatric patients. The other Panel members appointed were: Dr Tim Exworthy, a consultant forensic psychiatrist at Oxleas NHS Foundation Trust. Stuart Wix is a forensic nurse consultant at Birmingham and Solihull Mental Health Foundation Trust. Mike Lindsey is a former deputy director of social services at Shropshire County Council. Professor Tom Sensky, a Professor of Psychological Medicine and a consultant psychiatrist, provided expert advice to the Panel. 2 Acknowledgements The co-ordination of this Inquiry was undertaken by Derek Mechen of Verita to whom we are indebted for his indefatigable support. His inordinate patience and efficiency made our difficult and lengthy task that much easier and his sensitive handling of the investigation progress benefited all concerned. He really was the „backbone‟ of this Inquiry. We also could not have done without the rest of the Verita team who provide an excellent service to Inquiries generally. We are also grateful to the wonderful team from the Fiona Shipley Transcribing Service for their unflagging efforts in recording and transcribing the evidence for us. They endured long and tiring hours with efficient good humour. We are grateful for the frank and open way in which the witnesses gave their evidence to us. Although some of the key personalities had already had to give evidence to the internal inquiry panel which investigated and reported shortly after the homicide of Brian Cherry, for most of the witnesses this was the first time that they had been questioned in any way about their involvement with Peter Bryan or (where applicable) their managerial responsibilities within the various services involved with him. We appreciate the tolerance with which those who had already been put through the stress of an internal inquiry approached yet further questioning on a stressful topic. --------------------------- We also wish to acknowledge the event which gave rise to this Inquiry. Although we have of necessity had to concentrate mainly on Peter Bryan in this Report, Brian Cherry must not be forgotten. It seemed as though it was only too easy to forget the man himself in the media frenzy which surrounded his shocking and untimely death. If this Report and the Recommendations which we suggest can in any way prevent another such tragic event, then we hope that that will be a fitting memorial to a man much loved and missed by his family. The decision to anonymise this Report was made by NHS London and not by the Inquiry Panel. 3 Statement on anonymisation When the Report was handed to NHS London in early October 2008 it had been expected that the Report would be published as it was written, with the names of all those witnesses we interviewed included. The only reason which has been given to us for not doing so is that anonymisation of such reports is now NHS London‟s policy, as the practice of naming individuals might otherwise inhibit professionals from giving evidence to such Inquiries. All we can say is that the 62 witnesses who gave evidence to us did so openly and frankly even though they did not know at the time that the Report would be published without their identities being revealed. Those Panel Members who have been involved in other Homicide Inquiries where the reports have not been anonymised have also not encountered any apparent reluctance by witnesses to speak openly. Unfortunately the anonymisation makes the Report difficult to read fluently, and it is sometimes hard to identify or remember the particular status of each professional. The Report deals with a very complex case in a protracted timeline of over 10 years, and clarity with regard to the roles and responsibilities of those professionals involved is extremely important. The potential confusion in identifying the many professionals we write about may mean that individuals are wrongly indentified and thereby are wrongly and unfairly judged. There is also the risk that individuals may not even be able to recognise themselves and therefore will not learn the necessary lessons. It is also regrettable that those professionals whose involvement with Peter Bryan we praised may not get the recognition they deserve. Jane Mishcon Dr Tim Exworthy Stuart Wix Mike Lindsay 4 Contents Part one Introduction 6 Background 14 Early Years and the Homicide of NS 17 Rampton Hospital 31 John Howard Centre 92 Riverside House 162 Topaz Ward 349 The Homicide of Brian Cherry 364 Part two Commentary and Analysis 375 Map of Key Locations 376 The Homicide of NS 384 Rampton Hospital 388 John Howard Centre 409 Riverside House 457 Topaz Ward 618 The Homicide of Brian Cherry 646 Recommendations 667 Appendices Appendix A – Terms of Reference 682 Appendix B – List of Interviewees 685 Appendix C – List of witness mentioned in the report 687 5 Introduction In the early evening of 17 February 2004, Peter Bryan killed Brian Cherry in his own home by hitting him over the head with a claw hammer. He then dismembered the body and removed some of the exposed brain which he then fried in a frying pan and ate. The homicide occurred within a very few hours of Peter Bryan leaving the acute psychiatric ward at Newham Centre for Mental Health where he had been an informal (voluntary) patient for the previous week. As will be seen in the full report, Peter Bryan was in Hospital for his own safety, not because he was thought to be mentally unwell at the time. Although he had been an informal patient and therefore able to leave the hospital at any time, Peter Bryan had not in fact done so over the previous week. That morning he had asked for permission to leave the ward for a few hours, and he had left the hospital somewhere around 15.00 that afternoon. Shortly after 18.00, Brian Cherry was killed and dismembered using tools (a claw hammer, a Stanley knife and a screw driver) which Peter Bryan had purchased on the way on to Brian Cherry‟s flat. This was the second time that Peter Bryan had killed someone by hitting them over the head with a hammer. On 18 March 1993, when he was 23 years old, he had killed NS, the 20-year-old daughter of his employer. Although he was not known to the psychiatric services at that time, he was subsequently found to have been suffering from paranoid psychosis/paranoid schizophrenia at the time of the killing and was convicted of manslaughter on the grounds of diminished responsibility. At the end of 1993 he was sent under Section 35 of the Mental Health Act 1983 (MHA)1 to Rampton High Secure Hospital where he remained until July 2001. He then spent a period of six months at the John Howard Centre, a medium secure unit in Hackney before being conditionally discharged to Riverside House, a 24-hour supervised forensic hostel on the Seven Sisters Road, London N4. 1 35 MHA: Subject to the provisions of this section, the Crown Court or a Magistrates‟ Court may remand an accused person to a hospital specified by the Court for a report on his mental condition. 6 Peter Bryan had been a resident at Riverside House for almost exactly two years when he committed the second homicide. When he was arrested at Brian Cherry‟s home within an hour or so of the killing, Peter Bryan was apparently quite calm and showed no obvious signs of psychotic illness. The following morning, Peter Bryan was assessed by a consultant forensic psychiatrist who considered that he was fit to be interviewed by the police and did not need a hospital bed. Peter Bryan was charged with the murder of Brian Cherry and was sent initially to Pentonville and then to Belmarsh Prison. There was, however, a gradual deterioration in his mental state over the next couple of weeks and his behaviour became so unpredictable that on 15 April 2004 he was transferred to Broadmoor Hospital under the provisions of section 48 of the Mental Health Act 1983. He was originally placed in seclusion on Luton ward, the Admissions/Assessment ward, but three days later he was let out of seclusion because he was considered to have been “settled”. He was placed on a regime of „general observation‟. Just seven days later he attacked a 60-year-old fellow patient on the ward, Richard Loudwell. At first he tried to strangle him with the cord from his tracksuit bottoms but then he apparently smashed his head on the table and the floor. Richard Loudwell later died from his injuries. Peter Bryan was charged with the murders of Brian Cherry and Richard Loudwell and in October 2004 an application was granted to join the two indictments so that the two counts of murder could be tried together. In preparation for the trial, four psychiatrists (two for the prosecution and two for the defence) provided reports for the court expressing their opinion that Peter Bryan was seriously mentally ill, and the prosecution subsequently acknowledged that at that time of both homicides Peter Bryan was suffering from a severe mental illness and accepted his plea of not guilty to murder but guilty of manslaughter on the grounds of diminished responsibility. 7 On 15 March 2005 there was a sentencing hearing at the Central Criminal Court (the Old Bailey).