The Barrett Inquiry

John Barrett, a 41-year-old man with a history of schizophrenia and violence, was conditionally discharged from a medium secure forensic psychiatric unit in October 2003 following his conviction for a knife attack in 2002. Despite concerns about his compliance with medication and his capacity to recognise signs of relapse, the clinical team supported his discharge, subject to conditions including regular contact with mental health professionals and compliance with medication.

In October 2003 John Barrett was conditionally discharged by a mental health review tribunal. He was readmitted to hospital informally on two occasions in 2004. The inquiry report stated that in August 2004, he suffered a relapse but the clinical team did not take sufficient action. On 01 September 2004, he was admitted to the hospital as an informal patient but was inappropriately granted *leave and absconded. The following day, he fatally stabbed a member of the public, Denis Finnegan, in Richmond Park. [*Note: there are normally no formal leave procedures for patients who are informal. A conditionally discharged patient admitted informally is still ‘informal’.] 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.

The subsequent Inquiry(424 pages) identified several critical failings in Mr Barrett’s care, including an underestimation of his risk, inadequate monitoring, and poor communication within the clinical team and with Mr Barrett’s family. Surprisingly to many, the Inquiry spent considerable effort investigating Section 17 leave, when Barrett was not detained at the time he committed the homicide [informal status whilst still conditionally discharged does not mean ‘detained’. The Inquiry concluded that Mr Barrett’s homicide was preventable and made several recommendations to improve the quality of forensic mental health services, including the need for robust risk assessments, effective communication, and close monitoring of conditionally discharged patients.

In this article, the analysis of findings and lessons to be learned were taken only from the inquiry report.

What went wrong

John Barrett’s period of detention at the Shaftesbury Clinic was characterised by the grant of extensive leave, both escorted and unescorted. This culminated in the fateful decision to grant him unescorted leave on the day of his informal admission to the hospital on 1 September 2004, shortly after which he killed Denis Finnegan. Note that he was informal. Not many psychiatrists are aware of that fact.

Informal admission (click)

Para 19 of the Inquiry Report: On 31st August the decision was made, in light of his deterioration, to admit John Barrett to hospital. He was told about this when he saw the team’s social worker on 1st September. John Barrett reluctantly agreed to informal admission, in preference to formal recall by the Home Secretary, although he did not consider admission to be necessary. The only symptoms he reported were the whispering voices which had been intermittently present for the previous three and a half months. He was admitted at about midday to the Shaftesbury Clinic. He expressed his unhappiness at being admitted to a secure unit, saying he believed that as an informal patient he should have been placed on an open ward.

Leave as an informal patient

Para 20: The original plan was that John Barrett would remain on the ward and be seen later that afternoon by the consultant psychiatrist in charge of his treatment. However, she telephoned the ward to say that she was no longer able to see him that day but would do so the following morning. She decided to allow him an hour’s leave in the hospital grounds. She stipulated that if he did not return from the authorised leave, she was to be informed and consideration would be given to requesting the Home Secretary to issue a warrant formally recalling John Barrett to hospital.

The Legal Framework

The Inquiry looked into the culture of leave practices focusing on Section 17 leave. This may appear unusual as Barrett was informal at the time he committed the homicide.

Speculatively the Inquiry likely looked deeply into Section 17 leave for several reasons:

1. Historical context: The examination of Section 17 leave provides crucial background on how John Barrett’s care was managed during his time as a detained patient. This history is important for understanding the overall trajectory of his care.
2. Risk assessment and management: The handling of leave perhaps offered insights into how the clinical team assessed and managed risks associated with Barrett’s condition over time.
3. Decision-making: Scrutinising leave decisions helped to evaluate the team’s clinical judgment and decision-making processes, which may have influenced later decisions, including the move to informal status.
4. Transition of care: Understanding how leave was managed perhaps shed light on how the transition from detained to informal status was approached.
5. Systemic issues: Any problems identified in the management of Section 17 leave might point to broader systemic issues in the hospital’s practices, which could have persisted even after Barrett became an informal patient.
6. Legal and policy compliance: Examining adherence to Section 17 requirements provides a measure of the overall compliance with legal and policy requirements, which might have bearing on later care decisions.

While Barrett was indeed an informal patient just before the homicide, the inquiry’s thorough examination of his earlier care under Section 17 leave was likely part of a comprehensive review to identify any shortcomings or lessons that could be learned from his entire course of treatment.

Section 17 of the Mental Health Act 1983 provides that a patient detained in hospital under the Act may only be granted leave of absence from the hospital by the responsible medical officer (RMO). [RMO was the appropriate terminology before the MHA 1983 was amended in 2007]. In the case of a restricted patient, there is the additional requirement that any such leave must first be authorised by the Home Secretary. As is normal practice, the Trust policy is that on granting leave the RMO will complete a leave form which thus provides evidence that the leave has been properly authorised. Each episode of leave granted should either be covered by an individual specific form or by a form granting leave within parameters between specified dates. These forms must be signed by the RMO (or person acting as RMO in the event of absence of the actual RMO through illness or annual leave). This responsibility cannot be delegated to a deputy such as a specialist registrar or a senior house officer. [Note: After amendments to the MHA 1983 in 2007, the term RMO was replaced by RC – the Responsible Clinician.]

Home Office Guidance

The Home Office has issued guidance to RMOs on making requests for leave. The following two paragraphs are taken from this guidance:

6. The Secretary of State recognises that well thought out leave, which serves a definable purpose and is carefully and sensitively executed, continues to have an important part to play in the treatment and rehabilitation of restricted patients by assisting their progress towards eventual discharge into the community. It also provides valuable information to help responsible medical officers, and the Home Office in managing the patient in hospital, and to all parties including the tribunal when considering discharge into the community.
7. It is important that leave programmes should be designed and conducted in such a way as to sustain public confidence in the arrangements as a whole, and so as to respect the feelings and possible fears of victims and others who may have been affected by the offences.

Concerns Regarding Leave in John Barrett’s Case

• It was found that during John Barrett’s time at the Shaftesbury Clinic, leave forms were rarely signed by the RMO, contrary to the expectation that they would be.
• The Inquiry also found that leave was granted to Mr. Barrett on an ad hoc basis, without a clear plan or purpose.
• There was also a failure to adequately consider the risks involved in granting leave, particularly in light of Mr. Barrett’s history of absconding and violence.
• The Inquiry concluded that the decision to grant Mr. Barrett unescorted leave on the day of his admission was ‘seriously flawed’ and contributed to the tragic outcome.

The decision to grant John Barrett unescorted leave on the day of his admission to the hospital on 1 September 2004, was a pivotal event leading to the tragic death of Denis Finnegan. This decision, made by Dr Gillian Mezey, the consultant psychiatrist responsible for Mr. Barrett’s care, was taken in the context of his informal admission status and the perceived stability of his mental state. However, the Inquiry into Mr Barrett’s care revealed that this decision was flawed and contributed significantly to the tragic outcome.

Dr. Mezey’s decision was based on several factors, including Mr Barrett’s informal admission status, the perceived stability of his mental state, and a desire to maintain a therapeutic relationship with him. However, the Inquiry found that these factors were not adequately considered and that the decision was taken without a thorough assessment of Mr Barrett’s risk. Specifically, the Inquiry found that Dr Mezey did not give sufficient weight to Mr Barrett’s history of absconding and violence, and that she failed to appreciate the potential impact of his informal admission on his state of mind.

The Inquiry concluded that the decision to grant Mr Barrett unescorted leave was seriously flawed and contributed to the tragic outcome. It stated that the decision was ‘a critical error‘ and that it was ‘made without a proper assessment of his risk and without adequate safeguards in place‘. The Inquiry also found that the decision was taken without adequate consultation with other members of the clinical team and that there was a failure to communicate the decision effectively to nursing staff.

Specific Concerns Regarding Leave

• January 2003: The clinical team applied for escorted community leave for Mr. Barrett, even though he had not yet been allowed any unescorted leave in the hospital grounds. The Inquiry found that this was not in line with normal practice, which is to proceed with leave on a graded and gradually increasing basis.
• March 2003: The clinical team was already considering an application for unescorted leave for Mr. Barrett, even though he had not yet been tested with escorted community leave. The Inquiry found that this suggested ‘haste rather than careful consideration‘.
• April 2003: Mr Barrett was granted extensive leave, despite concerns about his engagement with therapy and his ability to structure his time. The Inquiry found that the team was ‘driven by the target of securing his conditional discharge‘ rather than by a careful assessment of his readiness for leave.
• July 2003: Mr Barrett was granted unescorted leave to Covent Garden, a busy and potentially stressful environment, for his birthday. The Inquiry found that this was not an appropriate first use of unescorted leave and that ‘measured testing would suggest that low stress situations and venues should be chosen for the first few leaves’.
• September 2003: The clinical team applied for overnight leave for Mr Barrett, shortly before his tribunal hearing. The Inquiry found that this was not capable of providing useful evidence to inform the tribunal’s decision and that its value, if any, was ‘purely cosmetic‘.

The Inquiry concluded that the management of leave in Mr Barrett’s case was unsatisfactory and contributed to the tragic outcome. The Inquiry made a number of recommendations aimed at improving the management of leave for restricted patients, including the need for clear policies and procedures, proper risk assessment, and effective communication with the Home Office.

Lesson to be learned

The Barrett case highlights several crucial lessons regarding the granting of leave to informal patients and those subject to Section 17 leave:

1. Risk Assessment:

• A rigorous and comprehensive risk assessment must be conducted before granting leave, regardless of the patient’s legal status. This assessment should consider the patient’s history of violence, absconding, and compliance with treatment, as well as any current indicators of risk.
• The risk assessment should not be static but should be dynamically updated to reflect any changes in the patient’s mental state or behaviour.
• In the case of informal patients, the risk assessment should specifically consider the potential impact of their voluntary status on their state of mind and the risk of absconding.

2. Decision-Making:

• The decision to grant leave should be made by the RMO, in consultation with other members of the clinical team. It should not be delegated to junior staff.
• The decision-making process should be clearly documented in the patient’s notes, including the rationale for granting leave and any specific conditions or restrictions.
• In the case of informal patients, the decision to grant leave should be carefully considered in light of the patient’s capacity to consent to remain in the hospital and the potential impact of leave on their willingness to stay.

3. Communication:

• The decision to grant leave, and any associated conditions or restrictions, must be communicated clearly and unambiguously to nursing staff.
• There should be clear procedures in place for monitoring patients on leave and for responding to any concerns or incidents.
• In the case of informal patients, there should be clear communication between the clinical team and the patient about the implications of their voluntary status and the potential consequences of absconding.

4. Legal Framework:

• The granting of leave must be consistent with the legal framework governing the patient’s detention. In the case of restricted patients, this includes obtaining the Home Secretary’s consent for any leave.
• The clinical team must be familiar with the relevant legislation, guidance, and case law relating to leave and must ensure that their practice is compliant.
• The concept of ‘leave’ is often thought to be irrelevant to informal patients. Whilst there are no statutory procedures relevant to informal status and leave, there are common-law duties of care. Subsequently Rabone 2012 clarified the matter.

5. Patient-Centred Care:

• While public protection is paramount, the decision to grant leave should also consider the patient’s therapeutic needs and their right to the least restrictive environment compatible with their safety and the safety of others.
• In the case of informal patients, their capacity and autonomy should be respected, and they should be involved in decisions about leave as far as possible.

The Barrett case serves as a stark reminder of the importance of careful risk assessment, clear decision-making, and effective communication in the granting of leave to psychiatric patients. By learning from the mistakes made in this case, mental health services can improve their practice and reduce the risk of similar tragedies in the future.