Report of the Independent Inquiry Into the Care and Treatment of Matthew Martin A report commissioned by Avon, Gloucestershire and Wiltshire Strategic Health Authority Published July 2003 1 PREFACE We were commissioned in July 2000 by Avon Health Authority to undertake this Inquiry. We now present our report, having followed the terms of reference and the procedure which was issued to all witnesses and their representatives. GILLIAN DOWNHAM ANDREW PROCTER Barrister MA, MBBS, PhD, FRCPsych ALISON CAMPBELL COLIN CLARK MA, CQSW, PhD MSc, RMN, RGN 2 ACKNOWLEDGEMENTS Our grateful thanks are due to all of the following William Evans for his energy, thoroughness and patience at the task of providing secretarial support to the inquiry. His care and dedication as the public face of the Inquiry has ensured that the procedure has run smoothly, with witnesses and organisations given every assistance. Harry Counsell & Company for their quick and accurate transcription services. Members of the family of the late Michael Martin and Matthew Martin for their co-operation in an emotionally demanding process. All witnesses for giving willingly of their time and memories. Steve Mulley for his tolerance as the representative of the commissioning agency Ruth Shakespeare for her advice on the continually evolving state of mental health services in prisons Roger Pedley for his advice on the ever changing face of local health purchasing and provision Elaine Rowland for her valuable advice on report presentation and her precision proof reading 3 CONTENTS PREFACE........................................................................................................2 ACKNOWLEDGEMENTS ................................................................................3 CONTENTS .....................................................................................................4 Chapter One ....................................................................................................8 INTRODUCTION .............................................................................................8 Chapter Two ....................................................................................................5 OVERVIEW OF SERVICES ............................................................................5 A summary ...................................................................................................5 General Practitioner Services.......................................................................5 NHS Child and Adolescent Mental Health Services .....................................5 General NHS Services .................................................................................6 Private Health Services ................................................................................6 NHS Psychiatric Services.............................................................................6 Social Services.............................................................................................7 Criminal Justice System ...............................................................................8 Court Diversion and Liaison Schemes .........................................................9 Probation......................................................................................................9 Prison Healthcare Service............................................................................9 Local Authority Housing Services...............................................................10 Combined Statutory and Voluntary Housing Services................................10 Voluntary Sector Housing Agencies ...........................................................11 Related housing and social services provision not accessed by Matthew Martin or arranged on his behalf.................................................................11 Chapter Three................................................................................................15 THE HISTORY...............................................................................................15 Early History...............................................................................................15 From the age of 17.....................................................................................16 First evidence of mental illness ..................................................................17 Diagnosis of psychosis in HMP Bristol .......................................................18 Southmead Hospital ...................................................................................18 Medication and management in hospital ....................................................19 Psychiatric reports for court........................................................................20 Arranging accommodation prior to hospital discharge................................20 Improvement in Matthew Martin’s mental health ........................................21 Discharge from hospital and s37................................................................21 After Discharge...........................................................................................23 The nine months after hospital discharge...................................................24 Accessing mental health services ..............................................................26 Loss of contact with mental health services ...............................................29 HMP Exeter................................................................................................31 Probation and psychiatric reports for court.................................................31 Release from HMP Exeter..........................................................................32 After release from HMP Exeter...................................................................33 HMP Bristol ................................................................................................33 The final six weeks .....................................................................................34 4 The killing ...................................................................................................35 The aftermath.............................................................................................35 Chapter Four..................................................................................................37 MENTAL HEALTH SERVICES ......................................................................37 Care Programme Approach (CPA): national guidelines .............................37 Matthew Martin’s entitlements under CPA and s117..................................38 CPA in the Trust and Social Services.........................................................38 Hospital Discharge December 1996...........................................................39 CPA meeting and care plan .......................................................................39 Social work.................................................................................................41 Planning for non-compliance and disengagement......................................42 Care co-ordinator .......................................................................................43 Risk assessment ........................................................................................43 Housing ......................................................................................................44 S117 aftercare............................................................................................46 Discharge from s37 ....................................................................................46 Discharge from CPA...................................................................................47 User and carer access to mental health services.......................................49 ‘Sectionability’ under the MHA....................................................................49 Chapter Five ..................................................................................................53 PRISON AND CRIMINAL JUSTICE SERVICES............................................53 Prison .........................................................................................................53 Background to prison health care...............................................................53 Inspection reports.......................................................................................54 Mental health services in prison .................................................................54 HMP Exeter................................................................................................56 HMP Bristol ................................................................................................57 Prison reception health screening ..............................................................58 Mental health assessment and treatment in prison ....................................59 Confidentiality.............................................................................................60 Getting information in .................................................................................60 Getting consent ..........................................................................................61 Confidentiality of the psychiatric report.......................................................63 Confidentiality of the probation report.........................................................64