The Coroner's findings into the deaths of David Gerard and Michael Eldridge delivered 9:30am, 13 December 2006. Report is listed at http://www.courts.
sa.gov.au/courts/coroner/findings/index.
html
An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 4th, 5th, 6th, 7th, 8th, 18th and 19th days of September 2006, the 14th and 17th days of November 2006, and the 13th day of December 2006 , by the Coroner rsquo;s Court of the said State, constituted of Elizabeth Ann Sheppard , a Coroner for the said State , into the deaths of David Gerard and Michael Eldridge .
The said Court finds that David Gerard aged 56 years , late of 105 Huckel Road, Karte died at Karte , South Australia on the 12th day of September 2001 as a result of a stab wound to the chest .
The said Court finds that Michael Eldridge aged 55 years , late of 31a Elder Terrace, Glengowrie died at the Royal Adelaide Hospital, North Terrace, Adelaide , South Australia on the 16th day of April 2003 as a result of multiple stab wounds to the chest .
The said Court finds that the circumstances of their deaths were as follows:
1. Reason for joint Inquest
1.1.
A decision was made to hold a joint Inquest into the deaths of David Gerard and Michael Eldridge because these two men were killed by persons who had been diagnosed with a mental illness and had previously been managed by the State's Mental Health Service. The incidents in which Mr Gerard and Mr Eldridge were killed are otherwise unrelated and occurred 18 months apart. It is now accepted that at the time Mr Gerard and Mr Eldridge were fatally stabbed, Anthony Butler and Barry Simper acted whilst in a psychotic state, thus rendering both men mentally incompetent to commit murder.
1.2. Mr Butler had a history of one episode of violent behaviour in 1997, in the setting of substance abuse, at which time he was diagnosed with schizophrenia.
During a twenty month Court ordered period of supervision on licence in Glenside Hospital, Mr Butler was required to abstain from illicit drugs and alcohol and to comply with a prescribed medication regime. He demonstrated reluctant compliance until the day he was released. As soon as his licence expired in March 2000 Mr Butler cut his ties with the mental health service and stopped taking his prescribed medication.
He travelled to Pinnaroo and then interstate via Melbourne to Sydney where he lived on the streets of Kings Cross for about six months. During this time he is said to have possessed a knife, was abusing drugs and alcohol, and was unwell. He travelled back to South Australia in September 2001.
The fatal stabbing of Mr Gerard occurred impulsively lsquo;during a brief period of extreme anger rsquo;, against a background of chronic paranoid ideas whilst Mr Butler was in a severe psychotic state(1).
1.3.
At the time of Mr Eldridge's death, Mr Simper was living in the community. He had numerous admissions to hospital over a period of 10 years to treat his chronic schizophrenia. One month before fatally stabbing Mr Eldridge, Mr Simper was detained and hospitalised following a severe relapse of his mental illness.
Over the following three weeks Mr Simper was managed in a closed ward setting, under detention, between Glenside Hospital and The Queen Elizabeth Hospital (TQEH), during which time he was sometimes violent and aggressive. When Mr Simper was discharged, his treating doctors considered that he had settled sufficiently to be discharged back to the community. Whilst they would have preferred Mr Simper stay in hospital a little longer, and spend a few days in the open ward at TQEH, in their view there was insufficient justification to detain him for an additional period under the Mental Health Act (1993).
In hindsight, it is now clear that at the time of Mr Simper's discharge he remained quite unwell and was under medicated. His previous history illustrated a pattern in which one could predict that Mr Simper would take much longer than a few weeks to settle and that during these periods, he was likely to be aggressive and violent. The fatal stabbing of Mr Eldridge in a hotel in Adelaide six days after Mr Simper's discharge from TQEH was subsequently held by the Supreme Court to have occurred whilst Mr Simper was acting in a psychotic state.
1.4. Evidence received during the Inquest examined the circumstances in which Mr Butler and Mr Simper were managed by the Mental Health Service in the time leading to their release into the community and whether relevant practices, systems, legislation and resources could be improved to reduce the likelihood of a recurrence of events similar to those leading to the deaths of Mr Eldridge and Mr Gerard.
1.5. It is acknowledged that the passage of time between the involvement of treating medical practitioners and the time of giving evidence has compromised the ability of these practitioners to recall certain aspects of their involvement, particularly with respect to Mr Butler's management.
Notwithstanding these deficiencies, the evidence overall enables me to make findings relevant to the circumstances culminating in these two tragic deaths.
2. Circumstances leading to the death of David Gerard
On 12 September 2001, David Gerard was with Mr Butler at a camp site in Karte, about 25 kilometres north west of Pinnaroo, when insulting words allegedly uttered by Mr Gerard caused an angry reaction in Mr Butler, whereby Mr Butler produced a double edged throwing knife from his pocket and stabbed Mr Gerard in the chest, piercing his heart and killing him.
Mr Butler made an attempt to hide his actions by moving Mr Gerard's body about 60 metres away, wrapping it in a sleeping bag and covering it with leaves and twigs to disguise it. When Mr Gerard's friends inquired as to his whereabouts, Mr Butler told them that he had gone for a walk. On 14 September 2001, a friend reported Mr Gerard missing to the local police officer who questioned Mr Butler later that day(2).
Mr Butler had some turpentine in his rucksack which he later explained he intended to use to dispose of Mr Gerard rsquo;s body. When Senior Constable Peter Mann was about to examine the rucksack, Mr Butler suddenly admitted that he had killed Mr Gerard by stabbing him because Mr Gerard had provoked him during an argument(3). It is accepted that around the time of the stabbing, Mr Butler had been consuming marijuana and alcohol.
3. Post mortem examination of David Gerard
3.1.
On 17 September 2002, a post-mortem examination was conducted by Forensic Pathologist Dr John Gilbert at the Royal Adelaide Hospital Mortuary. Dr Gilbert observed a near horizontal stab wound measuring 2 x 2.5 centimetres to the central chest which extended between the fourth and fifth ribs into the left pleural cavity and left lung.
Dr Gilbert described the fatal injury to the heart as follows:
lsquo;The wound then crossed the left lateral aspect of the pericardium, causing a 7cm long horizontal defect over its lateral aspect. The pericardial defect exposed a similar 7cm long slice-like stab wound involving the lateral aspect of the mid portion of the left ventricle. The central 3cm of the left ventricular wound was full thickness (i.
e. extending through the full thickness of the left ventricle).(4)
3.
2. Dr Gilbert located 1300ml of liquid and clotted blood in the left pleural cavity. No other injuries were noted including defensive injuries to the arms or hands.
I take this to indicate that there was virtually no opportunity for Mr Gerard to attempt to deflect the knife away from his chest before he was stabbed.
3.3.
I accept the observations made and opinions formed by Dr Gilbert and find that the cause of Mr Gerard rsquo;s death is a stab wound to the chest(5).
4. Criminal proceedings arising out of the death of David Gerard
4.
1. In criminal proceedings for the murder of David Gerard, Mr Butler successfully raised a defence of mental incompetence pursuant to s269 Criminal Law Consolidation Act 1935 (SA). Psychiatrists Kenneth O'Brien and Chris Branson provided reports in which they expressed the opinion that at the time of the alleged offence, Mr Butler was suffering from chronic paranoid schizophrenia and was psychotic.
On the basis of these opinions, Mr Butler was found to have been mentally impaired and therefore not guilty of the murder of Mr Gerard. The reports indicate that Mr Butler had probably been suffering from this chronic illness for about 6 years.
4.
2. His Honour Justice Lander noted that the evidence suggested that Mr Butler's mental illness 'is capable of being controlled to some extent by medication but only if the accused is prepared to submit to and to continue with that medication'(6) (my emphasis).
4.
3. On 14 January 2003, Mr Butler was committed to detention and ordered that he be liable to supervision for the period of his life. Mr Butler is now 41 years old.
In Dr Branson rsquo;s opinion, it will be essential that if Mr Butler is released into the community on licence, that he receive antipsychotic medication lsquo;under the closest possible supervision rsquo;(7).
5. Mr Butler rsquo;s background
5.
1. Mr Butler is said to have a history of violence when he was a child. He trained as a nurse between 1990 and 1992, but was unable to establish employment in the profession and remained unemployed.
In interviews with various health professionals, Mr Butler has spoken about a history of depression and psychiatric intervention to deal with that. He acknowledged abusing alcohol and illicit substances from an early age. A consistent theme in the various psychiatric reports concerning Mr Butler is the difficulty each psychiatrist has encountered in getting him to engage with them and to talk about his psychotic symptoms.
Amongst the challenges in managing Mr Butler has been his tendency to conceal his symptoms, as well as his limited insight into his illness.
5.2.
Mr Butler rsquo;s first episode of violent behaviour
Mr Butler first came to the attention of the Criminal Justice System and the South Australian Mental Health Service when he was alleged to have committed an act of threatening to kill his stepfather with a knife in August 1997.
5.3.
The incident involved Mr Butler attending the home of his mother and stepfather after they had retired for the evening. Acting under a delusional belief that his stepfather had abused Mr Butler's daughter, Mr Butler raised a sharp knife over his stepfather who was lying in bed beneath him and threatened to kill him. The intervention of Mr Butler's mother defused the situation until the police arrived about forty-five minutes later.
This was clearly a terrifying ordeal for his mother and stepfather and is the first indication of Mr Butler's propensity for extreme violence when actively psychotic(8).
5.4.
Mr Butler was taken into custody and detained in James Nash House where he was assessed as suffering from paranoid schizophrenia. Treatment was commenced which included the administration of antipsychotic medication.
5.
5. Abuse of drugs and alcohol while on bail
After considering a number of reports from psychiatrists who had evaluated Mr Butler in James Nash House, he was found to have suffered from a mental impairment at the time of the incident concerning his stepfather and was therefore found not guilty of the offence of lsquo;threaten life rsquo; on 23 February 1998. He was released on bail on the basis of psychiatric opinion provided to the Court which indicated that Mr Butler was stable enough on medication to be released, on condition that he comply with psychiatric treatment regarding medication and medical appointments.
5.6. Three weeks after being released on bail, Mr Butler is said to have started drinking heavily and consuming illicit drugs.
He admitted himself into a detoxification unit at Warinilla. When Forensic Psychiatrist Dr Craig Raeside reviewed Mr Butler at about this time, he reported to the Court that Mr Butler was at high risk of further relapses of his schizophrenic illness despite the use of antipsychotic medication and further, that his substance abuse would need close supervision. Whilst Dr Raeside considered that Mr Butler's prognosis was guarded, he supported release on licence into the community, but warned that if he continued to abuse substances, there was a risk of further offending(9).
5.7. After his release again in March 1998, Mr Butler commenced a thirteen week course known as the 'Bridge Programme' run by the Salvation Army to deal with drug and alcohol abuse.
During this period, Dr Maria Tomasic, Senior Registrar in Forensic Psychiatry at James Nash House, reviewed Mr Butler and reported that he appeared to be complying with his oral medications, but he had little insight into his condition and the need for the medication(10).
5.8.
When Dr Raeside reported to the Court again the following month, he expressed concern that Mr Butler returned to alcohol abuse so soon after being released on bail and stated that if Mr Butler lapsed from the Bridge Programme, the prognosis may be lsquo;far more guarded rsquo; or lsquo;not good at all rsquo;(11).
5.9.
Absconding whilst on bail
Mr Butler failed to attend a scheduled appointment with Dr Tomasic on 17 June 1998 and made no contact. He was said to have been lsquo;unsettled rsquo; during the Bridge course and quit the programme on 19 June 1998. The evidence suggests that Mr Butler ceased his medication and was later found in a dehydrated lsquo;almost catatonic rsquo; state in the Northern Territory.
He was admitted to hospital in Alice Springs on 22 June 1998 and brought back into custody and readmitted to James Nash House on 30 June 1998 where he remained for the next five months.
5.10.
In Dr Tomasic's report to the Court dated 15 July 1998, she expressed the view that this episode represented an acute exacerbation of his chronic schizophrenia probably due to non-compliance with his medication. Whilst there was no evidence available to Dr Tomasic to indicate what if any role alcohol or drugs may have played in this episode, it could not be ruled out as a contributing factor(12).
5.
11. Mr Butler was granted release on licence by Judge Anderson on 27 November 1998 for a period of twenty months to reside at Glenside Hospital, subject to conditions that Mr Butler abstain from alcohol and other illicit substances and that he comply with the treatment plan and undertake testing for the presence of alcohol and illicit drugs as directed(13).
5.
12. Period spent lsquo;on licence rsquo; at Glenside Hospital
On 9 December 1998, Mr Butler was transferred to Glenside from James Nash House as an lsquo;extended detainee rsquo;. The summary of his admission prepared by Dr Nance, the then Registrar at James Nash House, is brief as follows:
lsquo;Mr Butler is currently an extended detainee found not guilty by reason of mental impairment.
Prior to this admission he had been released to the community on licence. However, at that time he stopped taking his medication and for reasons he could not describe, went to Alice Springs to see Ayers Rock. He became dehydrated and was admitted to hospital at Alice Springs.
On admission Mr Butler was able to provide little information about his behaviour, but denied specific psychotic symptoms. His stay in James Nash House has been marked by aloofness and a reluctance to engage in conversation with staff. He has continued to deny psychotic symptoms.
Mr Butler has been granted licence and is being transferred to Glenside Hospital. rsquo;(14)
5.13.
The remainder of the discharge summary noted that the principal diagnosis was 'schizophrenia' and additional psychiatric problems included depression (in remission), alcohol and substance abuse. At the time of discharge from James Nash House, Mr Butler was receiving an injection of Zuclopenthixol deconate 200mg every two weeks, Olanzapine 20mg each night and Sertraline 100mg each morning.
5.
14. It is noteworthy that the psychiatric reports generated for the benefit of the District Court criminal proceedings were not made available to medical and nursing staff at Glenside Hospital who became responsible for his management and ultimately his discharge into the community. Nowhere in the Glenside Hospital medical notes is there any comprehensive summary of the facts of the violent conduct which led to Mr Butler rsquo;s detention in the first place.
Without this information, I consider that the multidisciplinary team responsible for Mr Butler's future management were only able to speculate about Mr Butler's risk of harm to others in the event of non-compliance with medication. In Dr Branson rsquo;s opinion, this type of information is necessary, but it requires someone taking the initiative to search for it(15). I say more about this topic later.
5.15. Mr Butler was transferred firstly to the closed ward, known as Kurrajong at Glenside and then Eastwood and the Glen open wards.
He was said to be supervised by consultant psychiatrists Dr Clayer, who was very ill over much of this time, Dr Harry Hustig, the clinical Director of Glenside Hospital and part time consultant Dr Mark Scurrah. Dr Scurrah, who has practised interstate for the past several years, explained that he had absolutely no recollection of being involved in Mr Butler rsquo;s management at Glenside Hospital. The absence of any notation in Mr Butler rsquo;s medical file which might be attributed to Dr Scurrah suggests that he was not actively involved, but may have been one of the consultants responsible for the ward which housed Mr Butler at the time of his discharge.
He is named as lsquo;the consultant rsquo; on Mr Butler rsquo;s discharge summary.
5.16.
The career medical officer responsible for the day ndash;to-day medical management of Mr Butler was Dr Marion Drennan. During the course of Mr Butler's time at Glenside Hospital, he was administered the same medications as he was receiving at James Nash House as well as Omeprazole 20mg each morning.
5.
17. Essentially, Mr Butler completed his period lsquo;on licence rsquo; without incident. The bulk of Mr Butler's time in Glenside Hospital was characterised by minimal communication or interaction with nursing staff and other patients.
He made it clear that he was simply lsquo;serving his time rsquo;.
5.18.
He was said to be in remission and did not display any active features of his illness throughout his period of detention. It is fair to say that he complied reluctantly with the conditions of his licence. If not for his licence conditions, there would have been no clinical basis to keep Mr Butler hospitalised.
His management was largely left to the psychiatric nurses supplemented by monthly clinical reviews with consultants attending if they were available(16). Having considered the entries in Mr Butler rsquo;s Glenside Hospital notes, it seems clear that there was very little by way of psychiatric evaluation of Mr Butler whilst he was at Glenside. I have no doubt that he was not regarded as requiring the level of intervention necessary for the majority of other patients housed at Glenside.
5.19. Dr Marion Drennan
Dr Drennan commenced at Glenside in 1998 as a junior practitioner responsible for the day-to-day general health concerns of patients.
She did not have training in psychiatric medicine at that time. Dr Drennan negotiated an agreement with Drs Hustig and Clayer in which it was accepted that decisions concerning the psychiatric management of extended detainees would be made by the consultants. This arrangement occurred around the time that a patient who had stabbed and killed a female career medical officer at Hillcrest Hospital in 1992, was transferred to G1enside(17).
Dr Drennan made some decisions for lsquo;voluntary rsquo; patients concerning their psychiatric management under the supervision of the consultant psychiatrists, but for extended detainees such as Mr Butler, she deliberately refrained from making any decisions about them or taking any actions which might be regarded as creating a potential risk to her safety. Dr Drennan gave evidence about her involvement in Mr Butler rsquo;s management, repeatedly stating that it was the role of the consultants to make any decisions regarding Mr Butler rsquo;s psychiatric management. Dr Drennan explained that she had a huge workload and while she worked at Glenside, there were insufficient sessional consultants to provide adequate support(18).
I formed the impression that this special arrangement concerning Dr Drennan, whilst understandable, was quite impractical. According to Dr Hustig, since Dr Drennan rsquo;s departure, there are now medical officers who are prepared to be actively involved in psychiatric management of the extended detainees (now referred to as forensic patients) and that this seems to be working well.
5.
20. Applications by Mr Butler rsquo;s defence counsel for trial leave
On 23 September 1999, District Court Judge Anderson granted an application to vary Mr Butler's licence conditions to enable him to leave the hospital grounds between 5:00pm on Fridays and 5:00pm Sundays. Mr Butler's medical records indicate that he was permitted leave of this description regularly and that he was compliant with conditions attached to his leave.
On 2 February 2000 he was granted a further variation to enable longer periods of leave between 10:00am Wednesdays to 5:00pm Sundays. Again, the records indicate that Mr Butler was granted leave regularly between these times without incident in excess of 60 days. Random drug and alcohol testing confirmed his abstinence from illicit drugs and alcohol during this period.
According to Dr Hustig, these periods of approved lsquo;leave rsquo; were regarded as a prudent way of gradually integrating a detainee back into the community before his licence expired.
5.21.
Plans undertaken for Mr Butler rsquo;s discharge and follow-up
According to Dr Drennan, it was common practice at Glenside to consider and plan the type of support a patient would be requiring once they were discharged, from the time they were admitted to hospital(19). In Mr Butler's case, his licence was due to expire on 24 March 2000. In April 1998, even before Mr Butler's charge of murder had been dealt with, a social worker recorded in Mr Butler rsquo;s medical file that an application had been made for priority housing through the Housing Trust.
Notwithstanding numerous follow-up attempts by the social worker and encouragement for Mr Butler to provide adequate documentation in support of his application and to participate in an interview, the application was not processed in time for his discharge in March 2000. It is well known that the Housing Trust has enormous demands upon its facilities. According to Dr Drennan, the social worker at Glenside Hospital was under a great deal of pressure, given the type of patients housed in Glenside(20).
In the circumstances, it seems to be a complete waste of the social worker rsquo;s time to try to organise letters of support for applications for housing when the main problem seems to be that there is not enough public housing to meet the demand. It was never going to be easy to secure appropriate priority housing from the Housing Trust for an uncooperative person such as Mr Butler and yet, in this case, I find that the issue of housing was a critical factor to the success or otherwise of any follow-up in the community, which was necessary in his own interests and in the interests of the community.
5.
22. Dr Drennan emphasised that she was not responsible for the discharge planning upon the expiration of Mr Butler rsquo;s licence. Entries in Mr Butler rsquo;s medical file indicate that arrangements for discharge planning were shared mainly between, Clinical Nurse Consultant Orr, Registered Nurse Bossenberry, Social Worker Ann Hillam and Dr Drennan.
Dr Drennan prepared the discharge summary intended to go to the general practitioner who was to provide ongoing management in the community.
5.23.
On 30 January 2000, RN Bossenberry referred Mr Butler for assessment by the Eastern Region, Mobile Assertive Care Team (MAC). If the MAC team agreed to provide their services to Mr Butler once he had returned to the community, they could have provided intensive follow up if required, but only if he remained in the metropolitan area(21). In the referral form seeking this assessment, Mr Butler is described by RN Bossenberry as presenting a low risk of harm to others(22).
Whilst the previous threaten life charge is mentioned, there is no detail provided which would alert the MAC Team to the potential risk of relapse or violent behaviour in the event that he was non-compliant with medication and resumed his intoxicant behaviour. There is no evidence however, which would enable me to find that if this information had been included, it would have influenced the decision ultimately made. No doubt there is great demand upon the services of the MAC Teams and at the time of the assessment, Mr Butler rsquo;s mental illness was in remission controlled by medication.
5.24. On 24 February 2000, Mr Butler was assessed by the MAC Team as not requiring their level of intervention and it was suggested that he be monitored in the community by the lower level of service offered by the Continuing Care Team (CCT).
This service was dependant upon housing becoming available, at which time Mr Butler would be assigned to the service which covers that region. In other words, without a specified place of residence, the service was unavailable(23). The community teams have nurses and social workers who monitor patients and encourage them to attend follow-up appointments at regional clinics for their antipsychotic injections and for review.
When properly resourced, this service is said to provide an early intervention mechanism when patients become non-compliant or relapse through drug and alcohol abuse.
5.25.
Psychiatric review of Mr Butler before discharge
An entry in Mr Butler rsquo;s Glenside Hospital notes on 17 August 1999 indicates that he was to be assessed by Dr Clayer to gauge his level of depression, yet this does not appear to have taken place. The only note by a consultant in the several months before his release is a brief one by Dr Hustig concerning Mr Butler rsquo;s trial leave arrangements on 26 November 1999. A report to Mr Butler rsquo;s legal representative dated 21 September 1999 was generated in response to an application to change Mr Butler rsquo;s licence conditions.
In Dr Hustig rsquo;s two page report, he mentions having an interview with Mr Butler, but that does not seem to have been noted in Mr Butler rsquo;s medical file(24). I accept that there may have been more direct assessment of Mr Butler by consultants than is reflected in the notes, but I have a concern overall about the lack of documentation which suggests that there was no formal clinical assessment of Mr Butler prior to discharge. This is all the more concerning, given that Dr Drennan took no responsibility for Mr Butler rsquo;s psychiatric management.
5.26. Mr Butler rsquo;s departure from Glenside without follow-up arrangements
On 22 March 2000 Mr Butler was permitted to leave the hospital for lsquo;trial leave rsquo;, after which time his licence expired.
The final entry explaining Mr Butler rsquo;s departure is made by Clinical Nurse Consultant Orr to the effect that Mr Butler was given oral medication for seven days and he is said to have agreed to see a local GP for a prescription for more medication. Mr Butler received his last injection of Zuclopenthixol deconate 200mgs on 20 March 2000. His next injection was due on 3 April 2000.
5.27. Mr Butler informed CNC Orr that he intended to reside at an address described as lsquo;Karte Hall via Pinnaroo rsquo;.
The note continues as follows:
lsquo;Anthony does not wish any community input from mental health services now his licence has expired! Anthony rsquo;s behaviour and conversation was appropriate and intelligent as it has been over the major part of his stay here. I have spoken to him re previous behaviours and drug use.
He is aware of the need not to use drugs as it will lead to further difficulties for him. He has agreed not to use illicit substances. rsquo;(25)
5.
28. Discharge Summary prepared by Dr Drennan
Dr Drennan explained in evidence that she had the task of preparing discharge summaries and when Mr Butler left the hospital, stating his intention to reside in Pinnaroo, she produced a discharge summary expecting that it would be faxed to a general practitioner (GP) in Pinnaroo. The document contains a brief outline of relevant information which I find was insufficient in the circumstances, although as things turned out, this deficiency is unlikely to have influenced the events which followed.
The fax cover sheet which might have specified who the discharge summary was sent to is absent from Mr Butler rsquo;s medical file and Dr Drennan was unable to recall that detail. Once Mr Butler rsquo;s licence expired, he was free to live where he wanted. The nearest community service available operated in Murray Bridge and was not an option for people with mental illness as far away as Pinnaroo.
In any event, Mr Butler had made it clear that he did not want community support. His departure to Pinnaroo marked the beginning of an itinerant period which saw him immediately stop taking his medication. He travelled interstate and resumed his illicit drug taking in Sydney, before returning to South Australia and ultimately back to Karte where he fatally stabbed David Gerard on 12 September 2001.
6. Review of Mr Butler rsquo;s management before discharge
6.1.
Inadequate communication with GP
Dr Ken O rsquo;Brien, Director of James Nash House and the Forensic Mental Health Service, became familiar with Mr Butler rsquo;s management when he was requested to provide the District Court with an opinion concerning the potential defence of mental incompetence. In evidence at the Inquest, Dr O rsquo;Brien expressed the view that Dr Drennan rsquo;s discharge summary was too brief and it should have been supplemented by the provision of additional psychiatric reports. He stressed that there needed to be a discussion between Dr Drennan and the GP at Pinnaroo and to make an arrangement for the GP to inform staff at Glenside if Mr Butler did not attend the surgery for his depot injections and prescriptions(26).
I endorse Dr O rsquo;Brien rsquo;s opinion on this topic, yet acknowledge that in Mr Butler rsquo;s case, once he had left the hospital, effectively, he was not compelled to do anything. The options were limited. Even if the local GP had received the discharge summary and took the trouble to contact staff at Glenside when a week had passed and Mr Butler had not made contact, according to Dr O rsquo;Brien, there was nothing anyone could do about it, other than to ask police to keep an eye on him(27).
6.2. Dr O rsquo;Brien explained that within the past fourteen months or so, resources have been made available for the provision of ten nurses linked with James Nash House to participate in the discharge plans for forensic patients following the expiry of their licences and to provide a limited supervisory role following discharge.
The James Nash House team is now said to handle the referrals to the MAC Teams and Community Teams. I endorse these changes which should improve the quality of arrangements made for post discharge follow-up in the community, subject to available resources. Unfortunately, the lack of services available to those discharged to most regional centres remains a major concern(28).
6.3. Mr Butler rsquo;s insight into his mental illness and the need for medication
In a report to the District Court for the purpose of considering an application to vary Mr Butler rsquo;s licence conditions in September 1999, Dr Hustig stated that Mr Butler demonstrated a 'reasonable insight into his current medication and the need to maintain his medication in the long-term'(29).
Yet the impression gained from the extensive notation by CNC Orr and others throughout Mr Butler rsquo;s period of detention, is that he was doing only what was required to get to the end of his licence period. In hindsight, it is difficult to see how the treating team could ever have had confidence that Mr Butler had insight into his illness and the need to continue taking medication following discharge. A perusal of Mr Butler's medical records indicates that CNC Orr, who was responsible for his day to day management and supervision, observed on 12 June 1999 that Mr Butler lsquo;requires prompting on almost every occasion to present for medication rsquo;(30).
6.4. One week before his discharge, CNC Orr made the following notation:
lsquo;Anthony is reluctant to do anything.
He needs to be encouraged out of bed every day. His appearance is dishevelled, dirty, without pride in his appearance. He is monosyllabic in and out of groups.
He is passive aggressive and surly most of the time. He complies reluctantly with ward routine and norms. rsquo;(31)
6.
5. When Drs Hustig and Drennan were questioned about this topic, both practitioners asserted that they saw no evidence to suggest that he would be non-compliant when discharged, having regard to the numerous times he had successfully completed trial leave(32). I accept that the evidence overall suggested, that Mr Butler was not refusing to take his medication whilst he was required to take it, in accordance with the conditions of his licence.
That is not to say that he would continue to take the medication once his licence expired.
6.6.
Alcohol and Substance Abuse
On the basis of Dr Branson rsquo;s interview with Mr Butler in 2002, he expressed the view that abuse of illicit substances and alcohol may not have been a major factor in Mr Butler rsquo;s acute episode of psychosis leading to the stabbing of Mr Gerard(33). On balance, I am inclined to accept the views on this topic by Drs Hustig and Raeside that it was a significant factor(34). Whilst Dr Hustig acknowledged that it was predictable that Mr Butler would resume drug taking at some stage, the difficulty was trying to predict when it might occur.
Given the potent nature of cannabis available, Dr Hustig claimed that it was not surprising that he developed psychosis when he resumed consumption of the drug(35). When Dr Hustig examined Mr Butler in November 1998, following the first episode of violent behaviour, he thought that it was clear that he would always be more physically aggressive in the setting of substance abuse such as cannabis or amphetamine and that this would often be complicated by the lsquo;co-use rsquo; of alcohol(36).
6.
7. Final lsquo;Trial Leave rsquo; when discharge arrangements were unresolved
Because the discharge arrangements were unresolved due to difficulties with accommodation, Dr O rsquo;Brien considered that Mr Butler should not have been granted the final period of trial leave(37). An alternative option was to give consideration to making an urgent application for a Continuing Detention Order but, in Dr O rsquo;Brien rsquo;s view, it would not have been appropriate to do this(38).
Dr Hustig suggested that there was insufficient clinical justification to merit such an application because Mr Butler rsquo;s mental state indicated that he did not need further hospitalisation(39). In Dr O rsquo;Brien rsquo;s view, there were pointers in Mr Butler rsquo;s history which should have alerted staff to the need to be very assertive in the way he was discharged(40). I accept Dr O rsquo;Brien rsquo;s opinion that, given the severe nature of the incident with his step-father, Mr Butler rsquo;s itinerant lifestyle, history of alcohol and drug abuse and intermittent non-compliance with medication, there needed to be a clear management plan(41).
6.8. I accept that Mr Butler did not need continued detention in Glenside from a clinical perspective, but I find that he should not have been granted lsquo;trial leave rsquo; when the question of housing remained unresolved immediately before his licence expired.
6.9. Mr Butler rsquo;s medical notes contain a large number of forms signed by medical practitioners authorising trial leave, however there is no form in the notes authorising this final period of leave.
Dr Drennan acknowledged that she signed many forms authorising Mr Butler rsquo;s leave up to the time of discharge, but could not assist the Court as to who authorised this final period of leave. According to Dr Drennan, she could not see a problem with Mr Butler being granted this final trial leave in the few days before his licence expired(42). The absence of this legal document in the case notes is a concern and suggests that the leave was not properly authorised.
6.10. Community Treatment Order option
In a report by Dr Branson in August 2002 concerning his assessment of Mr Butler rsquo;s mental state at the time when he stabbed Mr Gerard, the following observations were made about Mr Butler rsquo;s discharge from Glenside:
lsquo;It was of considerable concern to me that in view of Mr Butler rsquo;s history, no steps were taken to enforce antipsychotic medication on him at the time of his discharge from Glenside Hospital on 24.
3.00. In view of the fact that his Licence expired at that time, an order from the Guardianship Board such as a Community Treatment Order, would have been necessary to ensure that he continued to receive medication in the community.
No consideration was apparently given to applying for such an order rsquo;.(43)
6.11.
According to Dr Branson there was sufficient evidence in Mr Butler rsquo;s history to merit an application being made for a CTO, particularly the evidence which demonstrated that lsquo;when he became psychotic, he was inclined to become violent or threatening rsquo;(44).
6.12.
An application to the Guardianship Board for a Community Treatment Order (CTO) pursuant to Section 20 of the Mental Health Act (1993) required the applicant to demonstrate that Mr Butler was likely to fail to undergo treatment which should be given for his own health and safety or for the protection of other persons. The problem with this criteria is that it places a burden upon psychiatrists to provide sufficient evidence in support of the application and to estimate the degree of likelihood that the patient will become non-compliant in circumstances where the patient has not been adequately tested over an extended period of time in the community. Dr Hustig also expressed the view that the level of risk to the patient or others, which practitioners need to demonstrate in applications to the Board, seems too high.
Whilst the orders, if granted, provide the legal power to enforce treatment in the community upon reluctant patients, they do not authorise compulsory abstinence from illicit drugs and alcohol. Another shortcoming of these orders is that they are unenforceable interstate.
6.
13. According to Dr Hustig, the advantage of having an order in place for Mr Butler following discharge, is that it would provide a mechanism for early detection of deterioration in his mental state provided he resided in a serviced area within South Australia(45). However he considered that it was lsquo;extremely doubtful rsquo; that the Guardianship Board would have granted an order concerning Mr Butler in March 2000(46).
6.14. One major disincentive to making applications for CTOs was said to be the lsquo;culture rsquo; which previously existed within the Guardianship Board.
Drs O rsquo;Brien and Hustig explained that in about the year 2000, applications made to the Board were often unsuccessful because a legally trained senior member of the Board imposed a legalistic, adversarial style into the application process in which medical practitioners were subjected to intimidating questioning. Dr O rsquo;Brien explained that he had to stop the more junior practitioners from appearing before the Board because of the distress involved. An equally serious outcome of this phase in the life of the Guardianship Board was said to be that when applications were rejected, the lsquo;therapeutic alliance rsquo; between doctor and patient was irreparably harmed.
In this climate, practitioners are said to be very reluctant to make applications where there is a risk of rejection(47).
6.15.
Dr Hustig explained that at that time, even if a GP in Pinnaroo advised Glenside staff that Mr Butler failed to turn up for his required medication, that would not have been enough to justify making an application for a CTO(48). Clearly there is a problem with the way the legislation is being interpreted. I accept the evidence given by Dr Hustig on this topic concerning his experience with the Guardianship Board, endorsed by Dr O rsquo;Brien, and find that the demonstrated attitude of the former Guardianship Board to CTOs, prior to Mr Butler rsquo;s release from Glenside Hospital, influenced the treating practitioners to avoid serious consideration of this option in the ongoing management of Mr Butler in the community after his discharge.
According to Dr O rsquo;Brien, there have been changes to the Guardianship Board, which appear to have resolved this particular problem, although a measure of inconsistency and unpredictability remains(49).
6.16.
Dr Hustig suggested that there was a need for changes to the Mental Health Act (1993) to provide orders which require some patients to remain within the State, and to reside in a particular location. I accept that this would help community teams to more adequately supervise and treat patients in the community(50).
7.
Causal connection between the circumstances of Mr Butler rsquo;s discharge and the fatal stabbing of David Gerard
7.1. Having considered the evidence concerning how Mr Butler was released at the expiration of his licence from Glenside, I am satisfied that if he was released into the metropolitan area into suitable accommodation, community workers assigned to monitor his compliance with ongoing treatment may have been able to minimise the risk of an acute relapse, at which point he may have been successfully detained and treated in hospital.
One clear advantage of being housed appropriately would have been that he would be less likely to become itinerant. But taking into account his poor insight, history of non-compliance and reluctance to be monitored by community based mental health services, it would have been a challenge to keep Mr Butler compliant with prescribed medication and away from illicit drugs and alcohol in the absence of a CTO. When one considers the potential for Mr Butler to become extremely violent when unwell, I find that he posed an ongoing risk to the community which required the imposition of an appropriate level of monitoring of his behaviour for the foreseeable future.
I consider that a CTO should have been sought in a timely fashion prior to the expiration of his licence. If Mr Butler chose to travel interstate, then I accept that there is nothing which could be done to enforce the CTO in the absence of some form of national cooperative arrangement. If the Guardianship Board is not functioning as it is intended to, rather than tolerating an unsatisfactory situation to the detriment of their patients and the community, medical practitioners should be encouraged to raise the matter with their seniors, who should act on their concerns by bringing them to the attention of the Minister.
7.2. Because Mr Butler was not subject to a CTO, it should have been reasonably predictable that he would decline to engage with any service offered to him.
He was therefore able to cease medication and abuse drugs and alcohol until his behaviour attracted the attention of authorities, as indeed it did when he stabbed Mr Gerard. Given the passage of time between Mr Butler rsquo;s release into the community and the stabbing of Mr Gerard, I am unable to conclude that a CTO, if granted, would have altered the outcome. I find however, that if an order had been granted and successfully renewed twelve months later, subject to Mr Butler being provided with appropriate housing, the risk of what ultimately occurred would have been significantly reduced.
8. Circumstances leading to the death of Michael Eldridge
8.1.
On 10 April 2003 Mr Simper, aged 38 years, was discharged from the Cramond psychiatric unit at TQEH following a three week period of detention for an acute relapse of chronic paranoid schizophrenia, a condition for which he had been treated in hospital and in the community for ten years. Mr Simper rsquo;s psychiatric condition is complicated further by an anti-social personality. From 1992, Mr Simper had over fourteen psychiatric admissions to hospital, including James Nash House in 1994.
He had a documented history of aggressive and violent behaviour when he was unwell and a history of non-compliance with oral medication and other prescribed treatment.
8.2.
Mr Simper rsquo;s hospital and community mental health records are so extensive that it takes an experienced forensic psychiatrist at least five hours to review them(51). By all accounts, Mr Simper is a complex person to manage and one who requires an enormous amount of resources to manage successfully. I have been advised that whilst Mr Simper was at the extreme end of the spectrum of patients suffering this type of condition, there may be several hundred people like him in the community(52).
8.3. When discharged from hospital on 10 April 2003, Mr Simper was referred back to the community mental health team based in Port Adelaide.
Social Worker Michael Wooden was familiar with Mr Simper, having supervised him over a number of years in the community. He was well aware of Mr Simper rsquo;s potential violence and danger to others when he was under-medicated. He also knew that Mr Simper complained regularly to his doctors about sexual dysfunction, a common side effect of his antipsychotic medication (Zuclopenthixol) which was administered by injection each fortnight.
8.4. During 1999 and 2000 Mr Simper failed to attend outpatient appointments for medication and follow-up.
He was hospitalised five times within six months in 2000. During this time he is said to have assaulted two people and engaged in threatening, impulsive and destructive behaviour. After a period of extended detention in 2000, Mr Simper was eventually stabilised on a dose of Zuclopenthixol deconate 400mg per fortnight.
In April 2001 the dose was reduced to 350mg. In April 2002 it was reduced again to 300mg. Throughout this period, Mr Simper was required to submit to prescribed medication pursuant to 12 monthly CTOs granted by the Guardianship Board (53).
On one occasion in June 2000, police were called to assist the community nurse to administer the depot medication in his home. Mr Simper rsquo;s last CTO was due to lapse on 23 May 2003.
8.
5. Notwithstanding the CTO, Mr Simper was not reviewed by a medical practitioner for over twelve months before March 2003. The Port Adelaide Community Team doctor, Carlene Ward, assessed Mr Simper for the first time on 7 March 2003 and agreed to reduce his dose of Zuclopenthixol to 250mg and then to 200mg over two months and to start a trial of a new medication (Solian).
This was said to be done in response to Mr Simper rsquo;s complaint of sexual dysfunction. Dr Ward also told Mr Simper that another CTO would be sought to ensure his compliance with treatment. When Mr Wooden discovered that the depot medication was to be reduced, he was quite angry about it and raised his concerns with the practitioner.
When he took Mr Simper home after the appointment with Dr Ward, he raised the topic of the CTO which produced an aggressive response from Mr Simper who insisted that he would lsquo;get a lawyer and fight it all the way rsquo;(54).
8.6.
Mr Simper failed to attend the clinic to receive his fortnightly depot injections and on 17 March 2003, he refused an injection during a visit by the community nurse(55). As Mr Simper rsquo;s key worker, it was Mr Wooden rsquo;s responsibility to track Mr Simper down and encourage him to cooperate with the treatment. I accept that this was a very labour intensive exercise given the large number of patients subject to CTOs under his supervision(56).
8.7. As a result of the fatal stabbing of Mr Eldridge, the Clinical Director of Mental Health from TQEH, Dr Hundertmark, took the extraordinary step of writing to the then President of the Guardianship Board to complain about the fact that CTOs were being granted without recognition of the capacity of the Community Health Services to supervise them(57).
I consider that a more appropriate response to the problem might have been a request to the Minister for additional resources.
8.8.
In hindsight, it is now clear that with the gradual reduction in the dose of Mr Simper rsquo;s fortnightly medication and his non-compliance with treatment, his condition became unstable. By the time he was admitted to hospital on 17 March 2003, he was acutely unwell and dangerous. Neighbours are said to have noticed threatening behaviour by Mr Simper including hearing him say that he wanted a gun to shoot people.
During a visit to Mr Simper rsquo;s home that day, Mr Wooden was sufficiently troubled by what he encountered to arrange for an urgent assessment by Dr Geddes in the home, the outcome of which led to Mr Simper rsquo;s detention and transfer to TQEH.
8.9.
Dr Geddes had taken over from Dr Ward in the Port Adelaide Community Team. He completed paper work recording his assessment, which then became part of TQEH records for Mr Simper. Dr Geddes noted that this episode was an exacerbation of chronic schizophrenia, that Mr Simper had refused to take medication and was experiencing auditory hallucinations.
With reference to the criteria for detention under the Mental Health Act (1993), Dr Geddes documented that Mr Simper was a danger to himself and to others. Dr Geddes excluded any history of alcohol or drugs in this episode, but noted that Mr Simper had been well over the past twelve months lsquo;until 2 weeks ago rsquo;(58). In hindsight, it is clear that Mr Simper was becoming unwell for a much longer period than two weeks.
9. Failure of care provided in the community
9.1.
Having considered the evidence of events leading to this admission, the inescapable conclusion I have reached is that the management of Mr Simper rsquo;s chronic illness in the community was a failure. Notwithstanding the best efforts of those working in the community to keep him functioning, those efforts fell short of the type of supervision which Mr Simper needed for his own health and safety and the safety of others.
10.
Admission to The Queen Elizabeth Hospital 17 March 2003
10.1. Mr Simper was brought to TQEH in an acutely psychotic and aggressive state.
He was initially physically restrained, sedated and placed in a lsquo;seclusion rsquo; room where he was monitored by staff. On 18 March 2003 Mr Simper rsquo;s behaviour remained extremely disturbed. When he was released into the common room for a short period, he suddenly lunged at a male nurse who happened to be walking past him.
He punched the nurse to the face, wrestled him to the ground and continued to punch the nurse repeatedly until staff were able to intervene.
10.2.
The following morning Consultant psychiatrist, Dr William Goh signed documentation confirming Mr Simper rsquo;s three day detention order, noting his attack upon the nurse and the risk of further violence to others. In this documentation and also in Mr Simper rsquo;s progress notes, Dr Goh stated that Mr Simper had a history of schizophrenia with non-compliance and was experiencing command auditory hallucinations(59).
11.
Transfer to Brentwood Ward at Glenside Hospital 18 March 2003
11.1. In the afternoon of 18 March 2003, Mr Simper was transferred to the more intense closed ward in Brentwood at Glenside Hospital, where he remained aggressive and threatening over the next few days.
A very brief discharge summary, (prepared by Dr Chitrarasu and co-signed by Dr Goh), was provided to staff at Brentwood in which Mr Simper rsquo;s principal diagnosis was said to be lsquo;chronic schizophrenia ndash; acute exacerbation due to ?non-compliance rsquo;. I make no criticism of the decision to transfer Mr Simper for management in a closed ward at Glenside following the attack upon the nurse at Cramond.
11.2. When he arrived at Glenside, staff discovered that Mr Simper had $1,000 in cash in his possession.
In the closed ward at Brentwood, seclusion, restraint and sedation were employed to manage his continued aggression. I have no doubt that Mr Simper would have been an extremely difficult patient for staff to deal with. When Psychiatrist Dr Kneebone attempted to assess him, Mr Simper was said to be lsquo;malodorous, grandiose, irritable and threatening rsquo;.
On 19 March 2003 he remained hostile, abusive and threatening. Staff were required to restrain him to administer his depot medication. On 20 March 2003, Dr Kneebone reviewed Mr Simper and confirmed a 21 day detention order.
When Mr Simper was advised that he would be remaining in hospital, he tried to strike one of the nurses and later tried to strike a medical practitioner(60).
11.3.
After five days of intense supervision, medication and restraint in Brentwood, Mr Simper is said to have settled somewhat, but started to complain about sexual dysfunction again. On 25 March 2003 Mr Simper is said to have agreed to a period in an open ward and, from that time, he had to wait for an available bed in the open ward in Cramond at TQEH. While waiting, he expressed his anger and frustration about being detained in Brentwood.
He was non-compliant with his prescribed oral Sodium Valproate, hiding the tablets in his pocket. He also declined to take his nightly Haloperidol.
11.
4. By 28 March 2003, Dr Kneebone considered discharging Mr Simper directly back to the community from Brentwood. Entries in Mr Simper rsquo;s medical notes suggest that there was pressure on Dr Kneebone to discharge Mr Simper to free up his bed in Brentwood.
When Michael Wooden heard about the plan to discharge Mr Simper directly from Brentwood, he persuaded Dr Kneebone to keep him longer until an open ward bed became available.
12. Transfer to Cramond from Brentwood 4 April 2003
12.
1. On 4 April 2003, Mr Simper was transferred back to Cramond. The system operating at that time and currently, dictated that even though there was an open ward at Glenside Hospital, Mr Simper was required to be housed in an open ward at Cramond Clinic, subject to bed availability, because he was linked with the Port Adelaide area by reference to his residential address(61).
I accept the opinion from the Professor of Psychiatry at University of Adelaide, Dr Robert Goldney that Mr Simper rsquo;s illness was not sufficiently under control at the conclusion of this period in Brentwood to be transferred back to Cramond. He needed a longer period of review in a closed ward facility(62). Secondly, I accept Professor Goldney rsquo;s opinion that when Mr Simper was sufficiently controlled to be transferred to an open ward bed, he should have remained at Glenside under the care of the same treating team and be placed in an open ward there.
This would have achieved continuity of care and created less disruption at a time when Mr Simper remained irritable and under-medicated(63).
12.2.
When Mr Simper arrived at Cramond he was so irritable that staff decided to keep him in the closed ward. A cautious approach was adopted, taking into account what had occurred previously(64). He was prescribed Sodium Valproate 1000mg morning and night and Haloperidol 10mg nightly.
Lorazepam three times per day was commenced on 7 April 2003.
12.3.
Over the following week, Mr Simper was assessed in the closed ward by Dr William Goh and by Senior Registrar Dr Douglas Wilson. Dr Wilson had completed his training in psychiatry, but had yet to be admitted to the College of Psychiatrists. He was familiar with Mr Simper from an earlier period when he was his treating practitioner at the Port Adelaide Community Health Service about 18 months previously.
Dr Wilson had treated Mr Simper in that capacity periodically for at least two years and had known him to be non-compliant with medication for a schizo affective disorder. Dr Wilson was generally familiar with his multiple admissions to hospital following periods of non-compliance with medication(65).
12.
4. On 5 April 2003, Mr Simper was given two doses of oral Clopixol, an antipsychotic medication (prescribed on an as needed basis) as well as a tranquilliser (Lorazepam) after Mr Simper was observed speaking loudly, pacing the floor and becoming aggressive. When given the medication, Mr Simper is said to have stated that lsquo;he would murder someone, wouldn rsquo;t care who it was, just to get out and see his girlfriend rsquo;(66).
On the following day, 6 April 2003, he was given three more doses of PRN Clopixol. At 11:15pm he received 20mg Clopixol and 2mg Lorazepam.
12.
5. Before Dr Wilson assessed Mr Simper in the closed ward on 7 April 2003, he reviewed the notes of the previous three weeks including the faxed notes from Brentwood and the brief discharge summary. According to Dr Wilson, Mr Simper was hostile, irritable and angry about being kept in a closed ward when he had been told at Brentwood that he would be transferred to an open ward at Cramond.
He was prescribed a sedative, Lorazepam, three times daily and granted escorted trial leave for half an hour in the open ward at Cramond. According to a subsequent nursing note, this trial period took place without incident and Mr Simper appeared to be lsquo;superficially settled rsquo;, presumably as a result of receiving the extra medication.
12.
6. At 6:30am on 8 April 2003 Mr Simper was overheard by a nurse speaking on the phone to his mother lsquo;where he constantly discussed themes of anger and potential violence which included pointed and specific statements about nursing staff hellip; rsquo;(67).
12.
7. Dr Goh rsquo;s assessment - 8 April 2003
When Dr Goh assessed Mr Simper about five hours later in the closed ward, he is said to have done so without the benefit of looking at any of Mr Simper rsquo;s medical notes which recorded all previous notations by medical and nursing staff(68). Given the passage of time, Dr Goh was unable to say with certainty what information he may have been given before he reviewed Mr Simper.
Whilst Dr Goh agreed that he had ultimate responsibility for Mr Simper rsquo;s management, he explained that he had very little time available as a part time consultant and therefore relied heavily upon his registrar, Dr Wilson, whom he regarded as a lsquo;de facto rsquo; consultant(69).
12.8.
Dr Goh explained that he believed he was unfamiliar with Mr Simper when he interviewed him on 8 April 2003 and would not have recalled confirming the three day detention order following his initial detention and the attack on the nurse three weeks earlier. According to Dr Goh, his assessment made on 8 April 2003 was not a comprehensive assessment(70). He described it as lsquo;a cross-sectional view of someone in the ward who may need some additional opinion or contribution, rsquo; and it was based upon Mr Simper rsquo;s presentation over a period of 15 to 20 minutes(71).
Dr Goh rsquo;s entry in Mr Simper rsquo;s notes reads as follows:
lsquo;Appeared quite settled today after being prescribed Lorazepam over the past day and a half. Said that his main problems revolve around his feelings of frustration and anger, with rapid mood swings; frustrated as he had been impotent and this was affecting his relationship with his partner over last 2 years. Believed impotence is due to psychotropic medication.
Also six months ago heard that his children by previous relationship were killed in a motor vehicle accident. Still grieving their loss. Used to hear voices when using marijuana in early 1990s.
Voices stopped in 1995 also when he stopped using illicit drugs. Has a long track record of minor violent behaviour which he says was due to frustrations. He related well, reasonably articulate, range of affect appropriate, no overt delusions or hallucinations noted.
His story and presentation do not support a diagnosis of schizoaffective disorder unless there are data which I do not have. He probably had a drug induced psychosis and an underlying personality with difficulty in anger management. Currently depot medication to be reduced and at follow-up will require consultant review of his management at depth rsquo;.
(72)
12.9. I return to the topic of this assessment shortly when I discuss the opinions of psychiatrists who have carefully reviewed Mr Simper rsquo;s management with the benefit of hindsight as well as with more detailed historical information.
In essence, I find that Dr Goh rsquo;s assessment was flawed in several respects, but that even if he had been more thorough, Mr Simper would probably have been released from hospital on 10 April 2004 nevertheless. I acknowledge that had it not been for Mr Wooden rsquo;s insistence upon keeping Mr Simper until an open ward bed became available, Dr Kneebone may have discharged Mr Simper back to the community a week earlier.
12.
10. Having reflected on the evidence, I consider that Dr Goh rsquo;s assessment was influenced partly by the pressure on practitioners in his position to discharge patients as quickly as possible and to free up beds for more urgent cases(73). According to Dr Craig Raeside, it is a lsquo;nightmare rsquo; trying to balance the needs of patients occupying beds with patients who are waiting for those beds.
In his experience, whilst the hospital administrators insist that these decisions are for doctors to make on clinical grounds, Dr Raeside conceded that in reality there is enormous pressure with the limited number of available beds which in turn leads to patients being discharged prematurely(74).
12.11.
Dr Goh explained that he made a decision to retire early partly because he was unhappy with the changes to the mental health services which saw the concept of lsquo;asylum rsquo; abandoned and replaced by a short term approach involving speedy diagnosis, medication and discharge(75).
12.12.
Dr Goh acknowledged that if he had been in receipt of a comprehensive summary of Mr Simper rsquo;s longitudinal history, this might have influenced his assessment on 8 April 2003. I find however, that there was information available from the notes of Mr Simper rsquo;s admission on 18 March 2003 and subsequently, which if perused in a relatively efficient manner, should have influenced Dr Goh rsquo;s assessment of Mr Simper. An examination of Mr Simper rsquo;s medical notes, which covered the current admission, would have indicated that the history relied upon by Dr Goh, from Mr Simper, was factually incorrect in several critical respects,.
When Dr Goh came to write his entry in the notes on 8 April 2004, it would not have taken long to peruse the previous entries.
12.13.
I readily acknowledge how difficult it must be dealing with patients like Mr Simper, particularly when under time pressure, but as an experienced consultant it is surprising that Dr Goh contemplated a change to Mr Simper rsquo;s diagnosis without seeking corroboration of the history given(76). It appears that by considering a lsquo;drug induced psychosis rsquo; as the explanation for Mr Simper rsquo;s previous symptoms, Dr Goh was led to thinking short term which influenced his decision that Mr Simper did not require further hospitalisation(77).
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