Friday, September 11, 2009

Mental Health NHS Homicide Report Shows Devastating Failures


The full Report released on Sept 10th 2009 is downloadable now from the Strategic Health Authority is available HERE

The Report details a sad case of a Afro Caribbean man terrified of police and "MI5" intrusion into his life . By chance on the local street he walked into the police team sent to determine an approach to him . One might say events cascaded from there into the killing of Det Constable Swindells . Glaister Butler a paranoid and ill man felt he had to protect his own life by carrying a knife . He was eventually disarmed under threat of firearms .

From the Report :

"On 21st May 2004, on a canal towpath in Birmingham, Glaister Earle Butler lethally stabbed a police officer, Detective Constable Michael Swindells, who was, with a large number of other officers, trying to detain him. At the time Mr. Butler was a patient under the care of the Small Heath Assertive Outreach Team [AOT], following his discharge from in-patient treatment at Highcroft Hospital in October 2001 "

The Report does well to document failings described as :

'Pretty devastating'

Sue Turner, chief executive of Birmingham and Solihull Mental Health NHS Trust, apologised to the family, friends and colleagues of Det Con Michael Swindells and also to Butler for the shortcomings in his care and treatment.

She said the team was responsible for a "pretty devastating set of shortcomings" and promised that vast improvements had been made since.

The Report highlights the negative significance of treating a man with paranoid problems for years by reliance on the medical model alone and it emphasizes looking into a whole system approach assertively regarding the financial and social forces that he lived within, including his past stresses of being black and living inside a social system that was at times difficult .

From the Report we see a desire to shake some insights into the "community care" systems of mental health care delivery in Birmingham and elsewhere - its highly probable that some improvements have been made, and the Gov't have implemented Community Treatment Orders (CTO's) which mean much closer monitoring of medication can take place . Whether or not this may lead to other forms of patient-abuses is not known since CTO's are a fairly recent policy addition in the UK .

The Report also highlights the lack of a coherent social model "care plan approach" (CPA) which ideally would have taken into account Glaister Butler's aspirations and abilities (to help him train or learn) since he was a highly skilled design draughtsman at one time . That he needed help was simply missed and not monitored enough by a team .

More from the Report below :

13.4 Unhappily we suspect that many of the problems we have identified in this Inquiry are not confined to one Assertive Outreach Team in Birmingham and that there may be a case for a review of practice elsewhere. Unless the report is published in full this benefit may be prejudiced.

15.3 The Trust and the Strategic Health Authority should consider whether the issues in this report require a review of policy and practice in community mental health services generally in their respective areas and, to the extent that they consider that such a review is necessary, ensure that it is carried out and publish the results.

15.4 The Trust and the Strategic Health Authority should produce and publish a statement indicating the extent to which they accept the findings and recommendations in this report and the action taken to implement those recommendations which they accept.

17.2 CPA documentation during this period was sparse and did not detail sufficiently Mr. Butler‟s needs or what support for them was planned

25.4 The result was a focus on a medical model of care rather than a social one and a failure to devise exit strategies and targets for each service user. They did not seek out new ways of tackling difficult cases such as Mr. Butler‟s.

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