Professionals never engaged therapeutically with psychiatric patient before he killed

March 11, 2009
by Angela Hussain

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Mental 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.

In 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.

Barnet, Enfield and Haringey Mental Health Trust and Haringey Teaching Primary Care Trust were the centre of the investigation by NHS London.

"The investigation team considers this to be a significant factor that runs throughout all of the other critical issues and causal factors identified.”

Before the stabbings, Dogan had stopped taking anti-psychotic medication six months earlier and said he could hear God telling him to stab people.

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 departments.

• 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.

"We 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.

"There have been no homicides in Haringey committed by people receiving care from mental health services since the incident involving Mr. D in 2004."

Read for yourself:
NHS London's report into the care and treatment of Ismail Dogan (pdf)

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If professionals speak out they're marginalised

From: Russell Lutchman, consultant forensic psychiatrist, Berkshire.
Date: 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 puhleese!!

Many 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.

Oh 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.

Someone 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 always got.

P.S. 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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