I welcome this opportunity to raise certain tragic events that occurred in my constituency—events that caused widespread concern and deep grief; events to which the Secretary of State's response has been wholly inadequate.
On 30 March 1991 Carol Barratt was in the Frenchgate shopping centre in Doncaster, where she threatened a young lady with a knife. She was arrested, and later, following an assessment by a police surgeon, an approved social worker and the duty psychiatrist, was admitted to the psychiatric unit at the Doncaster royal infirmary under a section of the Mental Health Act 1983.
During her admission she appealed against her detention to the Mental Health Review Tribunal, but her appeal was turned down. Despite this, on 14 April the responsible medical officer—a Dr. Silvester—discharged her from her section of the Mental Health Act and she walked out of the hospital. Two days later—on 16 April —Carol Barratt went to the Frenchgate shopping centre and stabbed to death little Emma Brodie, an 11-year-old schoolgirl whose parents kept a nearby public house. The parents have not recovered from the shock and grief, and probably never will.
That such an appalling tragedy in such circumstances could occur was greeted first with total disbelief and then with furled anger in my constituency. The report of the fact-finding committee that was subsequently set up by the Trent regional health authority said that the responsible medical officer's decision to terminate her section
constituted a serious error of clinical judgment".
That severe indictment was expressed in even stronger terms by other people, particularly when it was learnt that Carol Barratt had also attacked a visitor during her detention prior to the killing.
The fact finding committee's report also contains the extraordinary statement:
although her responsible medical officer realised her dangerousness he nevertheless decided to discharge her from Section. In doing so he expressed the hope that the police would then get involved which could allow for more long-term detention of Carol to be arranged".
In other words, he thought, "Let her out; she is bound to do something bad and then we can have her back inside again." It is incredible, but that, as it turned out, is exactly what happened—with such terrible consequences for poor little Emma Brodie.
It is more incredible that the responsible medical officer could not take the trouble to attend the mental health tribunal, which, on 11 April, said of Carol Barratt:
She needs supervision and should not be released from the Section." '
Just how serious an error of clinical judgment occurred in the case can be fully measured only when viewed in the context of the report of the fact finding committee. The committee did a good job within its terms of reference and I pay tribute to its members for their much-valued work, but they suffered a serious handicap. The committee was set up by the Trent regional health authority.
Understandably, following the tragedy the little girl's father, Mr. Brodie, sought redress at law. For all I know, he may still be pursuing legal action—an action in which the same Trent regional health authority would certainly be joined, as the employer of the psychiatrist at the time that he made the fateful decision. An inquiry mounted by an organisation that needed to protect itself could not command the confidence of the public or anyone else— least of all anyone who might need the services of the psychiatry unit of the Doncaster royal infirmary.
I do not question the professional competence or the probity of those people who conducted the inquiry on behalf of the regional health authority, but their conclusions would have commanded greater support and confidence if they had been seen to be totally independent instead of appearing to act on behalf of an organisation with a vested interest in the outcome.
I pressed for an independent inquiry. For some other people that was not sufficient; they wanted a public inquiry. Those people who wanted a public inquiry, oddly enough, included the very Dr. Silvester who was responsible for the serious error of clinical judgment. I press for an independent inquiry. I do not want nurses grilled in public, but I think that we need to get at the facts of the matter. So far, I have pressed in vain.
You, Mr. Deputy Speaker, and other hon. Members will recall the tragic Beverley Allitt case. How was the inquiry into that case conducted? The Secretary of State for Health set up what she described properly as an "independent" inquiry headed by a distinguished Queen's Counsel, Mr. Cecil Clothier. If she could do that in the Beverley A llitt case, why could not she do that in the Carol Barratt case?
The Secretary of State said that she had intervened because of the "unprecedented scale and magnitude" of the Allitt case, but the House knows that one does not multiply grief. It is not magnified by numbers; it is total to the individual or the family that has suffered.
I call again tonight for a thorough, wide-ranging, independent inquiry into the circumstances that led to the death of Emma Brodie.
Perhaps hon. Members are wondering what disciplinary action was taken against the psychiatrist who committed that serious error of clinical judgment. He was sent for a course of training, which is now completed, and he is now back in a senior post with the Doncaster Health Care trust. I should add, before I pass on to other matters, that the fact finding committee paid a deserved tribute to the staff of the unit by referring to
a dedicated and enthusiastic staff giving good enlightened care ' to their patients".
I now turn to a rather different, but no less sad, case —the tragic death of Mr. Peter Savage. Mr. Savage was a patient in a general medical ward at the Doncaster royal infirmary. On 10 June 1993. he was fatally stabbed by another patient.
Once more, I pressed for an independent inquiry, but what we got was an internal inquiry led by Mr. Philip Gill, the retired former coroner of West Yorkshire. Again, I raise no question concerning Mr. Gill's probity or professional competence; but, as he himself pointed out in the introduction to his subsequent report, he was required not to investigate the circumstances leading to Mr. Savage's death. Instead, he was given the following terms of reference:
To review the admission, investigation and treatment of confused patients in acute health care settings in order to ensure the safety of services locally.
I have no complaint about the way in which Mr. Gill conducted his inquiry—nor do I question his subsequent
recommendations. But it was not the right inquiry. Why cannot there be an independent inquiry into the circumstances of Mr. Peter Savage's death? Again, I emphasise "independent". because Mr. Gill's inquiry was commissioned by the Doncaster royal infirmary and Montagu hospital national health service trust, the body responsible for the management of the unit in which Mr. Savage was killed.
Perhaps the Minister will say that the police investigation looked into the circumstances of the death. But the police were mainly or only concerned with factors that were relevant to a successful prosecution of the mentally disturbed man who did the killing. Questions that might touch upon the responsibilities of the hospital authorities in this matter would almost certainly have been outside their inquiries.
By way of contrast with the manner in which these matters have been dealt with in Doncaster, may I finally refer to the "Report of the Inquiry into the Care and Treatment of Christopher Clunis"? I have no intention of getting involved in the substance of that case, except to draw attention to the strong parallels with the killing of Emma Brodie, of which, in outline, it was almost a carbon copy. Christopher Clunis was a man with a history of mental disorder and psychiatric treatment who, without any apparent reason, stabbed to death a member of the public, Jonathan Zito, on 17 December 1992.
Although the subsequent inquiry was set up by the North East Thames and South East Thames regional health authorities, the report published late last month—just a couple of weeks ago—reflects a significantly more open and thorough approach than that of Trent region to which I referred earlier. Take the terms of reference for a start: there is no nonsense here about not inquiring into the circumstances that led to the person's death.
The inquiry, headed by Mrs. Jean Ritchie QC, was required first, to investigate all the circumstances surrounding the admission, treatment, discharge and continuing care of Christopher Clunis between May 1992 and December 1992; secondly, to identify any deficiencies in the quality and delivery of that care, as well as inter-agency collaboration and individual responsibilities; and, thirdly, to make recommendations for the future delivery of care including admission, treatment, discharge and continuing care to people in similar circumstances so that, as far as possible, harm to patients and the public is avoided. Why did we not have similar broad-ranging, far-reaching terms of reference for the cases in my constituency—and we certainly did not?
Mrs. Ritchie's committee of inquiry received evidence, written and oral, from a variety of experts, professional bodies and organisations and other interested parties. It received evidence from 143 witnesses. Those involved went out in pursuit of evidence—among other things, visiting Rampton hospital. They heard evidence from members of the public. All the witnesses are listed in the report, which runs to nearly 150 pages.
The Ritchie inquiry did an outstanding job of work and produced an excellent report. It deserves the thanks not only of the authorities that commissioned it but of all who care about mental disorders, not least those who suffer from them. I hope that its many recommendations are implemented and that its valuable lessons are learnt. I deeply regret that similar inquiries were not set up in those analogous Doncaster tragedies that I have described. If they had been, Mrs. Ritchie's task would have been lighter or perhaps even unnecessary. My constituents in Doncaster want to know why there have been thorough in-depth inquiries into cases in some parts of the country, but not in others—at least not in Doncaster.
The Allitt case received proper scrutiny on the initiative of the Secretary of State. There was a thoroughly professional inquiry in the Clunis case but in south Yorkshire, different and lesser standards seem to apply. It is not good enough and the Secretary of State should take steps to enable my constituents to feel that they will receive that to which they are entitled: equity of treatment and parity of care.
I am grateful to my right hon. Friend the Member for Doncaster, Central (Sir H. Walker) for allowing me a few minutes to speak in his Adjournment debate. I shall try to be as brief as possible because I am keen, as is my right hon. Friend, to hear the Minister's response.
Like my right hon. Friend, I pay tribute to the nursing staff in the Doncaster health care services. Under no circumstances should any blame for what has occurred be placed on nursing staff. Put purely and simply, the blame lies with bad management at health authority and regional health authority levels.
There has been a catalogue of disasters in Doncaster. The case involving the brain-damaged babies, the Silvester case and the Peter Savage case have been outlined very well by my right hon. Friend. As he pointed out, there has not been a public inquiry nor even an independent inquiry. Why should Doncaster be any different? Rightly, there was an independent inquiry into the Clunis case and its findings have been widely welcomed.
There has been a whitewash in each of the Doncaster cases. Internal inquiries were not open to public scrutiny. There was merely an audit of procedures to examine the brain-damaged babies case. Something different needs to be done. While the audit was welcome, it did not tackle the supposed problems that affected those babies.
Trent regional health authority set up another internal inquiry to examine the Silvester case. To add insult to injury, the doctor involved still works in Doncaster. Another internal inquiry was set up in the Peter Savage case. It amounted to an audit of procedures. In no way, shape or form did that inquiry even try to deal with what happened in the Peter Savage case or what went wrong —the inquiry was merely an audit of procedures.
Like my right hon. Friend, I believe that that is not good enough. Both Trent regional health authority and Doncaster health authority have failed miserably in their duties to the Doncaster public.
I have corresponded with the Under-Secretary of State for Health, the hon. Member for Bolton, West (Mr. Sackville), on the matter, raised it in parliamentary questions and even met the Minister to discuss it. I told him that the issue would not go away until it had been properly dealt with.
There has been and will continue to be local media coverage of and attention to the problem. I understand that the BBC is putting together a documentary film on the issue. A letter was sent to one of the shops in the Doncaster Frenchgate centre, where young Emma Brodie was
tragically stabbed. It gives details of the filming at the Frenchgate centre on Sunday 6 March 1994—last Sunday —and continues:
The filming is for Crime Limited a BBC 1 programme … in our forthcoming series".
That is a short quote from a very long letter.
When will the Minister understand that the people of Doncaster demand public scrutiny of all the cases that I mentioned? Even Dr. Silvester has said that he would welcome a public inquiry. I quote from an article in the Yorkshire Post on 23 June 1993:
He insisted lay members of the panel were not qualified to hear the case and said he would welcome a public inquiry to set the record straight.
Will the Minister now agree to a public inquiry, or even the independent inquiry that my right hon. Friend asked for, so that justice can be seen to be done in the Doncaster health care services?
May I first say what a pleasure it is to respond to a debate initiated by the right hon. Member for Doncaster, Central (Sir H. Walker). It is the first time that I have had the pleasure of doing so. He is, of course, a well-respected Member of the House. I congratulate him on securing the time to debate the issue of the mental health services in Doncaster and the tragic cases to which he referred. I acknowledge the contribution made by the hon. Member for Doncaster, North (Mr. Hughes).
All hon. Members will join in conveying our deep sympathy to the families and friends of Emma Brodie and Peter Savage, whose lives have been shattered by these tragedies. I am aware of the personal links that the right hon. Gentleman has with one of those families. The death of a loved one is always traumatic and difficult to come to terms with, but especially so under sudden and violent circumstances.
The proposal this evening is that there should be an inquiry into psychiatric killings in Doncaster. The right hon. Gentleman asked for an independent inquiry and specifically ruled out a public inquiry. The hon. Member for Doncaster, North preferred to ask for a public inquiry, although he said that he would accept an independent inquiry. Nevertheless, an inquiry has been asked for. The right hon. Gentleman cited the murders of Emma Brodie in 1991 and Peter Savage in 1993 as evidence for that.
In point of fact, I have to say that both tragic murders have been the subject not only of lengthy police investigation and judicial trials but of independent investigations set up by Trent regional health authority and the Doncaster royal infirmary and Montagu Hospital NHS trust respectively. In addition, the health advisory service has been investigating mental health services in Doncaster. That may be partly the answer to the right hon. Gentleman. Its report is due shortly.
In the case of Emma Brodie, Trent RHA established an independent committee of inquiry in April 1991 to look at the admission, care, treatment and discharge of her assailant, Carol Ann Barratt. The committee was chaired by Cyril Unwin, a former trade union member of Trent RHA and a justice of the peace, assisted by Dr. Dennis Morgan, consult psychiatrist at Queen Elizabeth hospital, King's Lynn, and Brian Smith, a Mental Health Act commissioner.
In its report, the committee made a number of recommendations. It recommended, for example, that the consultant psychiatrist—to whom the right hon. Gentleman and his hon. Friend referred—who authorised Carol Barratt's release should undergo a substantial period of supervised retraining outside the district. As a result, he was moved to Leicestershire district health authority in June 1992. The period of retraining ended, as the right hon. Gentleman said, at the beginning of January 1993.
But the RHA did not let the matter rest there. At its authority meeting in January 1993, Trent RHA considered the report of the doctor's supervising consultant during his retraining period and authorised his return to work only under certain conditions, including continuing supervision and training.
In the case of Peter Savage, Doncaster royal infirmary trust asked Mr. Philip Gill, the former coroner from west Yorkshire, who retired in August 1993, to conduct an independent inquiry into the admission, investigation and treatment of confused patients in acute health care settings to ensure the safety of the services locally.
The scope of the inquiry was announced on 6 October 1993 after extensive consultation with the police, the Crown Prosecution Service and my Department so that neither the defence nor prosecution were put in jeopardy. I am sure that that will be well understood. The inquiry's terms of reference were communicated to Members of Parliament representing Doncaster constituencies, to Mr. Savage's family, to the press and to the Department of Health; again, no objections were raised at the time.
The inquiry's report makes a total of 11 recommendations involving three categories—training, liaison psychiatry and guidelines. The recommendations that could be implemented immediately have already been acted on; others are subject to detailed consultation with clinicians at a national level, to ensure that the trust implements a policy that accords with best clinical practice.
Although Mr. Gill's inquiry did not report on the specific event of Mr. Savage's death, it did consider procedures for patients admitted with symptoms similar to those displayed by Mr. Savage's killer, Keith Emmerson.
The Minister said that, at the time when the Gill inquiry's terms of reference were announced, no objections were voiced. That was because we assumed at the time that, within those terms of reference, Mr. Gill would have an opportunity to do what he subsequently said that he was required not to do.
When the terms of reference were published, they contained no statement that Mr. Gill would not be required to look into the circumstances of Mr. Savage's death; and I for one had assumed that his terms of reference would allow him to do just that. It now seems that we were wrong. Perhaps Mr. Gill, or I, did not understand what the terms of reference meant, but the fact remains that the circumstances of Mr. Savage's death have not been inquired into. Why can they not be inquired into?
I think that the right hon. Gentleman is acknowledging that the terms of reference were brought to his attention, to the family's attention and so on. As he said, he did not understand that that excluded looking into the specific details.
In fact, I think it fair to say that it did not. In the course of his inquiry, Mr. Gill interviewed all the main witnesses to the event, and the people responsible for Mr. Emmerson's care. As I am sure the right hon. Gentleman knows, he also interviewed Mrs. Savage, in the presence of her legal adviser.
It is important to understand that Mr. Emmerson had never shown any signs of psychiatric disorders before and had never been in touch with any psychiatric service in Doncaster. He was admitted to hospital via the accident and emergency department, where he had presented himself, showing signs of confusion which at that stage could have been the result of a medical condition such as epilepsy: that is why he was placed on a medical ward, so that the exact nature of his condition could be established.
I understand that a number of valuable lessons have been learnt as a result of Mr. Gill's inquiry. For example, staff from the accident and emergency department, the transit ward and the medical ward have now been trained to assess patients with possible psychiatric conditions. More staff will undertake such training over the coming months. There are now better links between the psychiatric unit and the acute hospital and nurse practitioners in the psychiatric unit can be called on by the accident and emergency department for advice and help.
I thank the right hon. Gentleman, and the hon. Member for Doncaster, North, for their comments about the nursing staff in the hospitals. I am sure that all concerned will note those comments with gratitude.
As with the case of Emma Brodie, this case was investigated fully by the police before the trial of Keith Emmerson. An independent investigation has already reported, and I cannot see that anything would be gained from a further inquiry that has not already been obtained by the reports that we, and the health authority, have already received.
I understand that the chief executive of the Doncaster Royal Infirmary trust, Mr. David Nicholson, has recently been in touch with Mrs. Savage to answer her detailed and specific questions about the time leading up to and immediately after her husband's death. She has also been made aware of the action taken by the trust to minimise the possibility of such a tragedy's ever happening again. I believe that Mr. Nicholson has offered Mrs. Savage a chance to meet him and the staff involved in the care of her husband if she needs any further information or explanation.
The right hon. Gentleman, and other hon. Members from Doncaster and the surrounding constituencies, may recall that the Secretary of State for Health told the House in July 1993 that the Health Advisory Service would review mental health services in Doncaster. The right hon. Gentleman may take some comfort from that. The work is now complete and the results will be published shortly.
Carol Ann Barratt made her fatal attack on Emma Brodie shortly after her release from hospital. That was in 1991 and, since then, we have introduced the care programme approach which is intended to cover all patients being considered for discharge from mental illness hospitals and all new patients accepted by specialist psychiatric services. The needs of each patient for continuing health and social care and accommodation should be systematically assessed and effective systems should be put in place to ensure that agreed health and, where necessary, social care services, are provided to those patients who can be treated in the community. Explicit, individually tailored care programmes are drawn up and a key worker is identified to keep in close touch with the patient and ensure that the agreed package of health and social care is being delivered.
The best safeguards for patients and the public are still professional judgment, co-operation between services and a proper understanding of the powers that are available under the Mental Health Act 1983 and the limits that it imposes. That is why, in the case of Emma Brodie, it was right for the regional health authority to specify certain conditions under which this particular professional is able to practise.
I am sure the right hon. Member will join me in welcoming the action of Trent regional health authority and Doncaster district health authority in asking the Health Advisory Service to conduct the review of mental health service provision in the Doncaster area. It clearly demonstrates a commitment to securing the safety of the public and the best possible service for the mentally ill. I understand that the team will be making recommendations to local health authorities about future psychiatric provision.
I join the right hon. Gentleman and the hon. Member for Doncaster, North in expressing gratitude to all those who work in the medical and nursing professions and in voluntary organisations who do so much for mentally ill people. I am grateful for the opportunity to respond to the right hon. Member. I share his determination to ensure that high-quality treatment and care is available to mentally ill people, on a national level and locally in Doncaster, and that we learn from the experiences of past tragedies for the benefit of the patients and the local community. I believe that that is the best answer for the families of Emma Brodie and Peter Savage.