never engaged therapeutically with psychiatric patient before he
by Angela Hussain
health professionals never engaged therapeutically with a patient
in the four years before he randomly stabbed six people in London,
an inquiry found.
An independent investigation into the treatment of Ismail Dogan,
now 34, diagnosed with paranoid schizophrenia, revealed treatment
only ever involved anti-psychotic medication.
was never offered any psychological help during his four psychiatric
in-patient admissions. This was in spite of Dogan's parents requesting
psychotherapy for him in 2002.
March 2006 Dogan was found guilty of attempting to kill five people
in the street in London in December 2004. He admitted the manslaughter,
by stabbing, of Ernest Meads, 58, on the grounds of diminished responsibility
and was committed indefinitely to Broadmoor psychiatric hospital.
Enfield and Haringey Mental Health Trust and Haringey Teaching Primary
Care Trust were the centre of the investigation by NHS
"The failure to engage with Mr. Dogan is a hallmark of the
care and treatment that he received,” read NHS London's report.
investigation team considers this to be a significant factor that
runs throughout all of the other critical issues and causal factors
Before the stabbings, Dogan had stopped taking anti-psychotic medication
six months earlier and said he could hear God telling him to stab
He was well-known to mental health services.
No fewer than 23 "critical junctures" were identified
in Dogan's care and treatment.
Other key findings include:
• Dogan's parents tried five times to ask for help as he became
increasingly violent but no help was forthcoming, partly because
the mother could not speak much English and healthcare professionals
only called in translators "sporadically".
• Non-existent communication between in-patient and out-patient
• Poor communication between the police and the health trust.
In a joint statement, the two trusts said: “In the years since
2004 we have made significant changes to improve clinical governance
and risk assessment, care co-ordination and inter-agency communications.
have developed our policies which set standards and expectations
for our staff in relation to clinical supervision and we audit these
policies to ensure they are properly implemented.
have been no homicides in Haringey committed by people receiving
care from mental health services since the incident involving Mr.
D in 2004."
London's report into the care and treatment of Ismail Dogan (pdf)
speak out they're marginalised
Russell Lutchman, consultant forensic psychiatrist, Berkshire.
March 12, 2009
It’s a crying shame the stories are the same, only the names
are different. It is happening in many a mental health facility.
Each time a homicide is committed by a psychiatric patient, inquiry
reports say basically the same thing. We know the drill: 'Our work
practices and communications strategies have since been improved
- we wish the public to know that we have learnt the lessons'. Oh
of us psychiatrists working at the coalface know what is wrong with
these 'systems'. When we speak out we are bullied, marginalised
and moved on. Behind closed doors psychiatrists moan among themselves.
I’m sure somepme will respond by saying ‘No it ain’t
so in my neck o’ the woods’. That’s the usual
response and it's rubbish!!
Patients, carers, and
relatives really need to speak more with psychiatrists who are prepared
to speak out.
Many of the psychiatrists
who have been tarred and feathered in these kinds of reports are
not bad or incompetent people.
Psychiatry is a very
difficult and stressful job. You’re always playing with risk,
overworked and generally given very poor facilities to work with.
You’re so busy
fire-fighting all the time that you hardly have time to think and
to communicate effectively with others.
needs to do a different kind of inquiry! Eh? The kind that analyses
why systems became so chaotic across all these health services,
and then pinpoint dysfunctional management as high as an inquiry
needs to go. Then hopefully someone with some common sense and power
makes some heads roll.
But we don’t have
to do any of that. We could just continue doing as we’ve always
done – muddling along – and reaping what we’ve
Anyone wishing to have a brief polite chat about the above may call
me between 18:00 and 20:00 Mon-Fri on 07017 877355 (calls may cost
up to 35p/min depending on your call-provider. This is a measure
to deter crank callers. Calls may be recorded.)
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