Report of the independent inquiry into the care and treatment of John Barrett
This Homicide Inquiry was conducted following the murder of Denis Finnegan, a 50-year-old former banker, on 2nd September 2004: he was stabbed to death in a random attack as he cycled through Richmond Park. The perpetrator of this crime was John Barrett, who had suffered from paranoid schizophrenia for many years. As a voluntary patient in a medium secure unit, he had been given unescorted leave the day before he committed this offence. The inquiry found that the agencies involved in his care appeared to have made a number of mistakes, including a severe lack of communication. This high-profile case led to renewed calls for community treatment orders for high-risk mentally disordered patients.
- John Barrett was convicted of three serious assaults in January 2002. He committed the offences under the influence of abnormal mental processes. A restricted hospital order was imposed under the Mental Health Act 1983 on the grounds that his detention was considered necessary “for the protection of the public from serious harm”.
- In October 2003 John Barrett was conditionally discharged from detention under the Mental Health Act by a mental health review tribunal. He was readmitted to hospital informally on two occasions in 2004. On 2nd September 2004, the day after the second readmission, he was at large in Richmond Park where he stabbed to death a stranger, Denis Finnegan.
- Homicides committed by psychiatric patients are rare events and unprovoked fatal attacks on strangers are still rarer. The reconviction rate for violent offences committed by discharged restricted patients remains low and has not increased in recent years. This, however, can provide no comfort to Denis Finnegan’s family and friends. Every homicide committed by a psychiatric patient not only causes grief to those directly affected but gives rise to justifiable public concern. Where the perpetrator is a restricted patient under the Mental Health Act the public interest is necessarily greater because the legal regime gives particular emphasis to the protection of the public.
- It might be suggested that this tragedy would not have occurred if it had not been for a single decision, to allow John Barrett out on leave from the medium secure psychiatric unit to which he had been re-admitted on the day before he killed Denis Finnegan. This decision was an essential link in the chain of causation leading to Denis Finnegan’s death, but we consider it was only one of several instances where clinical interventions did not give sufficient weight to the risks John Barrett could pose to the public.
- This report shows that many aspects of John Barrett’s management as a patient of forensic mental health services were not attended to with sufficient thoroughness. Too much confidence was placed in clinical judgements unsupported by evidence and rigorous analysis. Ways of working did not facilitate effective discussion and challenge of clinical views. There was a tendency to emphasise unduly the desirability of engaging John Barrett rather than intervening against his wishes to reduce risk. There was insufficient regard for legal and good practice requirements. Trust management systems for monitoring and regulating the work of the Forensic Service were weak and poorly implemented. This amounted to a cumulative failure effectively to manage the risk John Barrett posed to others.
- The remedy for what went wrong in this case lies not in new laws or policy changes. Nor is there any reason to believe that an insufficiency of resources contributed in any way to the shortcomings we have found. The challenge, both organisational and individual, is to ensure that the care of potentially dangerous psychiatric patients is based on sound clinical practice and the systematic application of established principles of risk and organisational management. We do not make detailed recommendations about these matters because they are well understood by practitioners and managers. However, as discussed below we are concerned about the capacity of the South West London and St George’s Mental Health Trust to remedy the deficiencies we have found.
- In this report we comment critically on the performance of some of those who were responsible for John Barrett’s care and treatment. The individuals concerned were given the opportunity to respond to our criticisms. The question arises whether we have applied too high a standard when considering, with the benefit of hindsight, their acts and omissions. It might be suggested that we should have applied the standard used by the civil courts in adjudicating professional negligence claims, and specifically the Bolam/Bolitho test for clinical negligence. It could be argued that our failure to apply that standard amounts to arbitrariness that is unfair to the individuals we have criticised.
- We consider that this suggestion could arise from a possible misunderstanding of the nature of an Inquiry such as this which is, we believe, to demonstrate through evidence and argument the validity of our conclusions. We are self-evidently not a court. Neither our procedures nor the evidence enable us to make findings equivalent to those of a court adjudicating a disputed clinical negligence action. We bring to the task a range of experience and expertise which informs how we weigh up the evidence. This report reflects our consideration of the evidence, including extensive discussion between ourselves during the course of the Inquiry. We do not presume to lay down standards but rather to express our own considered views on a single case.
- We recognise that the views we express in this report, and the conclusions we reach, have to be based on a thorough and fair consideration of the available evidence. In Part 1 we set out fully the factual background. This is largely derived from the written records. Other written and oral evidence is referred to extensively in Part 2 where we consider the issues which arise for comment and discussion. We have tried at every point in Part 2 to demonstrate the evidential basis on which our views are founded.
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