Last week, Lee Dixon was ‘sentenced’ under s37/41 of the Mental Health Act having been found responsible for attempting to murder two police officers in Darlington. PCs John WOOD and Carl WOOD (not related) were commended by the Judge for their ‘considerable bravery’ in detaining Dixon as he made concerted efforts to stab one of the officers in the face. Each emerged from the incident with their stab-vests bearing piercings from the knife.
It could have ended so very differently and previously. It has done so on other similar occasions.
This case has prompted debates on blogs and comments elsewhere, not just from police officers. It seems to be causing the usual questions to be re-asked about apparently unpredicted or unpredictable violence by people with mental health problems.
- What does this mean about ‘care in the community’?
- Should Dixon not have been detained in hospital, given the risks he clearly posed?
- What does this mean about violence by people with mental health problems?
- What does this mean about the prediction and mitigation of risks?
CARE IN THE COMMUNITY
As far as I can establish at the point of writing, Lee Dixon was not known to mental health services in his area. Therefore, questions 1 and 2 should not apply. It means little if anything for ‘care in the community’ or inpatient care because mental health services were not given the opportunity to intervene: for whatever reason. It is like asking what the police were doing to mitigate risks for predatory or acquisitive offenders after learning they’ve never been arrested before, or featured in police intelligence about offending in any way. As police officers, we know that many of our offenders are well known, but that this can happen from time to time.
The movement towards de-institutionalised mental health care has been taken up the world over and is unlikely to change. Whatever police officers may think about this, it still needs policing properly. However, if you take time to learn about pre-1950s institutionalised care, one will see that it was not without significant problems in terms of crime and human rights. (Some critics will argue that inpatient care has not improved sufficiently since that time.)
VIOLENCE BY PEOPLE WITH MENTAL HEALTH PROBLEMS
Question 3 is harder to answer: questions are being asked in the case of Durham social worker Claire Selwood who was repeatedly stabbed in 2006 by a mental health patient who had disclosed to his psychiatrists before release from hosptial that he would kill her. She is currently appealing against a court ruling which rejected her claim that the NHS Trusts who cared for her attacker had failed to alert her to the risks and breached their duty of care. It will be interesting to see how the appeal proceeds given that the successful argument in the lower courts was simply that the NHS Trusts owed her no duty of care at all. Questions have been asked and answered in relation to the care and treatment of individuals like Ikechukwu Tennyson Obih who stabbed and killed PC Jon Henry in Luton in 2007; and Earl Butler who stabbed and killed DC Michael Swindells in Birmingham in 2004 where shortcomings were identified by the independent inquiries, but such investigations would not apply to Lee Dixon.
Questions about violence by people with mental health problems is politically sensitive for a range of reasons. Campaigners will argue that violence is under-reported, misunderstood and misrepresented. Professor Tony Maden, professor of forensic psychiatry at Imperial College, London, received some criticism following his 2007 book ‘Treating Violence’ wherein he described the link between schizophrenia and violence as being ” no longer controversial … there is a highly significant association between psychotic mental illness and violence in the community, of a similar order of magnitude to the association between smoking and lung cancer.” (Oxford, 2007, p23).
One is often greated with the non sequitor retort that mental health service users are far more likely to be victims of crime that perpetrators. Of course, these two prevalences are entirely unconnected. Whatever the statistical prevalence of each, one tells you nothing about the other. Moreover, it has been claimed that this claim comes from poorly conducted, not validated research without a control group or peer review. In three seperate research papers conducted on a group of 700 patients between 2001 – 2007, violent victimisation and commission was broadly similar at around 21-23%.
Well obviously, if someone who suffers from a mental disorder which may be associated with raised risks of violence is not known to or not engaged with mental health services, then the ability to predict risks will be limited or non-existant. The ability of criminal justice agencies to manage those risks will usually be limited to situtations where s136 MHA may be applied or where offences have already been committed. Of course, the police also can and do refer people at (all types) of risk to mental health services and other agencies to secure a multi-agency plan around how to mitigate risks. I do not know whether this could have happened Dixon’s case.
However, where patients have been known to the mental health services and then very seriously offend, there is an inquiry into their treatment and care with a view to ensuring that lessons are learned. There is now a large number of these reports – two more due shortly on the separate cases of Darren Stewart and David Neal – which all say roughly the same thing: information sharing and / or care planning and / or risk assessment and / or follow-up after disengagement. Tony Maden argues in his book for a closer examination of risk assessment tools, stands up for those tools which exist and suggests more robust use of them.
I once attended a meeting in an area who were looking at their forensic mental healthcare pathways. They brought together a multi-agency group of professionals to help bring different perspectives to bear on the problem of ‘early intervention’ – how to target services early on towards people with needs which put them at risk to prevent them the need for criminal prosecution and detention in secure care. They were currently spending 55% of their total MH budget on just 3% of their patients: those who were detained in medium and high secure hospitals following criminal sentencing under the Mental Health Act. The proportion of the budget spent on this group of patients had been rising for several years and therefore the remaining 97% of patients had access to dwindling resources which in turn made it harder to ensure early intervention to mitigate against others coming into contact with the criminal justice system.
Of course, the problem is how to identify from a whole population group that small cohort of inviduals who present the trigger factors for early intervention hoping it will mitigate against future risks. This starts to get into very difficult and complex ethical territory as there has been suggestion by some mental health professionals of medicating people in risks groups before the onset of illenss or offending. Of course, if Lee Dixon was unknown to services – for whatever reason – then his detention in secure care at approximately five times the cost of prison is unavoidable.