Adapted from the report of the inquiry supplied by Pat Fitzgerald, of
Southern Derbyshire Health.
Derwent Court, Stuart Street, Derby DE1 2FZ
Mounted as HTML by Chris Evans
C.Evans@sghms.ac.uk,
24.xi.96 within the
Section of Psychotherapy pages {7kb}
Names and some details have been changed. Where
names have been changed the substitutions are consistent, where
places have been changed this is not necessarily the case.
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On the 8th August 1995 xxx xxxx(1), in a deranged episode of violence at home, killed his mother, Mrs xxx and his young half-brother xxx. He later went to the surgery of his General Practitioner, Dr Yyyy, and asked that an ambulance be called and the police informed. He was subsequently arrested at the GP surgery, without further incident. He was detained and on the 6th March 1996 he appeared before the Crown Court in Nottingham and pleaded guilty to manslaughter. He was ordered to be detained, without limit of time, in Rampton Hospital.
In such circumstances, it is now current practice that the relevant Health Authority institutes an independent inquiry to review the events in detail and to make recommendations as appropriate.
We were appointed by the Southern Derbyshire Health Authority, the Derbyshire County Council and the Derbyshire Family Health Services Authority (2) at the end of January 1996, to undertake that task. An independent secretary was appointed to assist us. (3) We commenced work and held our preliminary meeting on 1st February 1996. (4)
We were given detailed Terms of Reference. (5) In addition we took into account that the judge who sentenced XX made it clear that he considered that there should be a full inquiry as to the circumstances that led to this tragedy. (6) We therefore determined to look as closely as possible at the background of XX's life and at all the detailed circumstances leading up to the terrible climax.
On appointment, we began a series of meetings of a general nature to familiarise ourselves with essential features of the background, being unable, until the trial of XX had been held, to speak to the crucial witnesses. Once XX had been dealt with by the Crown Court we were able to commence a series of meetings which took the form of consideration of the circumstances and implications of the relevant events in XX's life, his breakdown and particularly of the treatment he received after his illness led him to seek medical help. The meetings were held in private, in Derby. They were informal in nature, although a shorthand note was usually taken, and we sought to cover not only the facts surrounding the tragedy but also, more generally, the structure of care available and the way in which the various professional staff had identified and performed their roles. The names of witnesses, and the dates they were seen, are set out in Appendix IV.
At XX's father's request, we arranged the meeting at which he came to talk to us as late as possible in our inquiry. Understandably he wished for a period of grace before having to discuss, in some detail, the terrible tragedy that had occurred in his family. He asked that Jayne Zito of the Zito Trust and a colleague of hers be allowed to accompany him and we were pleased to agree.
Nothing that we do can undo what has occurred. We would like, however, at the commencement of our Report to express our extreme sympathy to Mr Peter X; to thank him for his co-operation; and to hope that he and his daughter find some consolation in the expectation that our Report may, at least to some extent, achieve its principal objective - to avoid similar tragedies that might otherwise occur.
Our Report has been structured, as the Table of Contents indicates, into various parts. We have first identified three relatively distinct phases -
A the period prior to XX entering hospital,
B his stay in hospital,
C the weeks following discharge.
Each of these phases is dealt with similarly. The events of each period are first summarised, in narrative form, covering all the facts and significant features necessary to support the following sections. The next section selects and discusses particular incidents and topics where it was felt that consideration and comment are likely to be helpful. The third section, covering each period, involves the setting out, as recommendations, of all those changes of attitude, approach or practice which we feel should be given serious consideration. These will be seen to vary in scope very considerably, covering for example, attitudes, general aspects of practice and in many instances fairly minute detail. All these have been chosen because it was felt that a weakness had been disclosed and some thought and action was required to see if matters might be improved.
We have decided to underpin this approach, which is largely thematic, by a brief chronology to which reference can be made to check where any individual point fits into the timescale. That will be found in Appendix III.
At a somewhat different level we believe that we have identified
six more general aspects that should be the subject of wider consideration
and debate. An example of these is counselling, a newly growing
profession, which has filled an obvious need. This and other matters
of similarly general application are dealt with in the second
chapter of our Report. They are counselling, admission to hospital,
treatment in hospital, a social circumstances report prior to
discharge, communications and the aftermath.
1) XXX XXX was referred to in our terms of reference as XX. Without any intention of disrespect, we decided that it would be appropriate to continue to refer to him in this way throughout our report.
2) subsequently the Southern Derbyshire Health Authority.
3) see Appendix I.
4) see Appendix IV.
5) see Appendix II.
6) see also
Appendix II.