The rising toll of homicide by psychiatric patients: have we reached ‘peak community care’?

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With a spring in his step, lecturer Jeroen Ensink left his suburban London home to postcards to his many friends around the world, announcing the arrival of his baby daughter. Seconds later his life was over. A young man had pounced, and in a state of frenzy, savagely stabbed his random victim (Daily Mail, 4 January 2016). As psychiatric patient, Femi Nandap begins detention in a high‐security institution, we should spare some thought for Jeroen's wife, and his only child.
‘Lessons will be learned’ is the typical response by health service managers to a homicide enquiry involving one of their patients Co‐author JH, after the unprovoked killing of his father in Bristol in 2007, started a campaign for safer care of the mentally disturbed, and a more supportive and honest response to victims’ families ( Examining details of 1274 killings by people with mental illness, JH found the same failings repeated again and again. Lessons do not seem to be learnt, and the dangerousness of a small but volatile subset of psychiatric patients is not taken seriously enough (Hundredfamilies, 2016a).
Myths around mental health policy persist. In ignorance of the creation of multidisciplinary locality teams and residential services, a simplistic notion tainted the perception of care in the community in the 1990s. Scandals of patients ‘slipping through the net’, with tragic consequences, suggested that patients had simply been abandoned after the mental hospitals were closed. Yet, much of the impetus for the shift from the former asylums to the community was from mental health campaigners, as a libertarian claim for rights, freedom and citizenship. This was a progressive development, not a penny‐pinching exercise (with their economy of scale, mental hospitals were cheaper to run).
Community care policy had bad press in the early years, but opposition has declined over the last 10‐15 years, partly because stigma and sensationalized media reporting have been challenged. However, this success has led to a censorial tendency. Three years ago, a front page of The Sun newspaper (6 October 2013) declared ‘1200 killed by mental patients’. This figure was taken from the National Confidential Inquiry into Suicide and Homicide (2013), which has collated data on incidents involving people with mental illness annually since 1999, but it was criticized for including deaths at the hands of persons judged to be mentally unwell but not current psychiatric patients.
Services cannot be expected to prevent incidents by unknown people, but numerous cases were arguably preventable through better access to mental health care. Each fatality was a mother, father, son or daughter; many of whose families believe could still be alive today if their assailant had received timely and effective intervention. Mental health campaigners were enraged by The Sun headline, and an undermining commentary in The Guardian (7 October 2013) ended with the question: ‘How would you want to see us reporting on mental health?’ Hundreds of readers’ comments condemned The Sun for allegedly provoking stigma, yet the article was reporting facts (the number of deaths was 1226, though incorrectly summed to 1216).
Much‐needed reform of mental health services is being obstructed by a well‐intended but perilous ideology of prioritizing the battle against stigma over public safety. At a recent trial of a man with a long history of mental illness and violence accused of murdering a stranger, James Collins, a consultant forensic psychiatrist at Ashworth high‐security hospital told the court (Blackpool Gazette, 14 July 2016):
This approach is at odds with the scientific basis of psychiatry. No other branch of medicine would eschew its own taxonomic framework in this way.
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