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									   Inquiries / Reviews / Complaints: completed / published / being set up /
            sought: Excerpt from the E-Bulletin of DSA: April 2008

                  Independent review into mental health homicides, NHS London, 3rd
                  March 2008
                  A review of 26 mental health homicides that were committed in London
                  between January 2002 and December 2006 has been published today. The
                  review recommends further independent investigations into all 26 cases to
                  ensure that lessons for improving the capital's mental health services are
                  learned. NHS London commissioned the independent review when it
                  discovered that 26 cases inherited from its predecessor organisations had not
                  been reviewed independently as stipulated under the terms of Health Service
Guidelines (94) 27. The purpose of the review was to identify common themes and any specific
cases that required further independent investigation. The review did not examine the
circumstances of individual cases.

Dr Simon Tanner, Regional Director of Public Health for NHS London, said: "These cases are
about real people and real lives. That's why NHS London is committed to learning everything we
can from them. We will investigate them fully and independently and use the findings to inform
the development of mental health care in London and continue to improve patient care and public
protection," he added.

Although all 26 cases were recommended for further investigation, the review concluded that the
same scale of investigation was not necessary or appropriate for all cases. The review
recommended three broad types:
     Type A - a wide-ranging investigation carried out by a team examining a single case
     Type B - a narrowly-focused investigation by a team examining a single case or a group
       of themed cases
     Type C - a single investigator (with peer reviewer) examining a single case or a group of
       themed cases.

Based on the complexity of each case and on the analysis of the internal investigations carried
out by mental health trusts, four cases were recommended for Type A investigations, 10 for Type
B and 12 for Type C. Further investigations into all 26 cases have been commissioned or are
being commissioned. They will be completed by the end of 2008.

             Full report

Murderer's family call for report, BBC News, 5th March 2008
The family of a Leicester man who was jailed for murder are calling for a report into his mental
healthcare to be made public. Scott Walker, 27, stabbed Debra Larn to death and seriously
injured her partner John Brightwell in September 2006. The family said they want the report to be
public so people can get a better understanding of mental health issues. The Leicestershire
Partnership Trust said a final decision has not been made about whether to release the report.

Walker's brother Danny said the family is not worried about revealing his brother's personal
medical details. His mother Christine said: "I need this report to become an open report so
everyone could read it and understand what is going on in these people's minds who suffer from
personality disorders. It might help somebody else and they might get the help that Scott didn't
get." Danny Walker said: "Scott did a terrible thing, but if he had got the help when he asked for
the help, none of this would have happened. It is all about Scott the murderer, but I want the
report to come out and want people to know what my brother was. He was no monster like people
make him out to be."

The trust said it would be inappropriate to comment until after the family has read the report and
discussed the content with them. Walker attacked John Brightwell, 50, and stabbed and killed
Debra Larn, 47 and was jailed for life in July 2007. After he was jailed, the judge warned Walker
that he might never be released because he had a personality disorder which makes him
dangerous to the public.

Killer ‘heard voices’ before chisel attack, Leicester Mercury, 5 March 2008
A "dangerous and deranged" man has admitted stabbing his neighbour to death with a chisel
after hearing "voices." Today the family of victim Karen Godden are demanding to know why
mentally-ill Kelvin Trenfield was at large in the community. The 32-year-old carpenter, of
Avonside Drive, Rowlatts Hill, has a history of paranoid schizophrenia and was discharged from a
mental heath unit months before the attack. Leicester Crown Court heard Trenfield had failed to
take his medication, but had smoked cannabis instead.

David Farrer QC, prosecuting, said the victim's 75-year-old mother, Lorna Godden, found her
daughter's body. She had been worried about not hearing from Karen, 51, for some time. The
court heard Karen and Trenfield did not get on since he began being noisy at night. Mr Farrer
said the defendant got into her flat, where she had lived for 20 years, and attacked her by
stabbing a chisel into her head through her ear. Mr Farrer said: "He believed the voices were
coming from TV sets." He destroyed all the TV sets in his flat, and the victim's.

Police found blood on Trenfield's trousers and an identical chisel to the killing weapon, part of a
set, at his flat. In police interview he made no comment but, while on remand in custody in
Leicester Prison, he phoned his mother and confessed, which was routinely tape-recorded. He
was later transferred to a secure mental unit at Leicester's Arnold Lodge, where he is expected to
continue receiving treatment. He admitted manslaughter on the grounds of diminished
responsibility, between August 14 and 17 last year. Trenfield was sentenced under the Mental
Health Act to be detained in hospital indefinitely.

In a statement issued after yesterday's hearing, Karen's sister, Rachel Mason, said: "It's
disturbing and shocking that in society today we're not safe in our own homes when there are
individuals like Trenfield with a history of mental illness living among us. Somebody has to be
accountable and take responsibility for placing this man in our community. He's dangerous and
shouldn't be in the community and by locking him away, it will ensure he can never do this again
to cause pain and suffering to another family." Three psychiatrists agreed he was suffering from
paranoid schizophrenia before and during the killing. Passing sentence, Judge Michael Pert QC
said: "You're an extremely dangerous individual." Steven Newcombe, defending, said Trenfield
"has very deep remorse".

Today a spokeswoman for Leicestershire Partnership NHS Trust, which runs mental health
services, said: "This must be a very distressing time for Karen Godden's family and we offer them
our sincere sympathy. If they would like to meet with a member of our staff to help in their
understanding of the situation, we would be happy to arrange this. It is standard procedure for
mental health NHS trusts to carry out a review of care if a patient is involved in a homicide.
Typically these reviews consider in detail the medical history and care provided to the patient. An
internal review into the care of Kelvin Trenfield has been completed by the trust. It is now with the
NHS East Midlands Strategic Health Authority, who will decide whether or not any further
independent review may be required in this instance."
                   NPSA works to improve mental health patient safety investigations,
                   National Patient Safety Agency press release, 13th March 2008
                   The National Patient Safety Agency (NPSA) today launched guidance aimed at
                   improving and standardising the approach to independent investigations into
                   serious patient safety incidents in mental health services. Independent
                   investigation of serious patient safety incidents in mental health services good
                   practice guidance describes the three main stages of the independent
                   investigation process in detail, examining the initial service management
                   review, internal NHS mental health trust investigations and Strategic Health
                   Authority independent investigations. The document also looks at how NHS
organisations can support the victims of serious incidents, families, carers and perpetrators, how
to support staff and other affected mental health users.

The initial service management review is an internal trust review within 72 hours of the incident
being known about in order to identify any necessary urgent action. The more in-depth internal
NHS mental health trust investigation uses root cause analysis or a similar process to establish a
chronology and identify underlying causes and any further action that needs to be taken and is
usually completed within 90 days of the incident. SHA independent Investigations are
commissioned and conducted independently of the providers of care.

The NPSA's Chief Executive Martin Fletcher said “We recognise it is essential that serious
incidents occurring in all care settings are investigated locally to ensure that, where possible,
urgent action is undertaken to protect patients and staff and that appropriate learning is shared
nationally. Our guidance for the mental health sector represents a framework of best practice to
enable the root causes of incidents to be identified and communicated in an open and honest
manner to all concerned. It is designed to guide staff through the process in a consistent manner
across the NHS.”

Health Minister Ivan Lewis said: "The vast majority of mental health patients receive safe and
effective care, however tragedies do occur. We must ensure that we are doing everything to learn
from them and to improve services accordingly.

Today's guidance will help ensure that mental health investigations across the NHS are carried
out in a consistent and coordinated way and involve families and relatives appropriately."

Jayne Zito OBE, Patron of The Zito Trust said: “Good practice guidance is needed to help those
involved in independent investigations communicate more effectively with victims and families.
The Zito Trust has been concerned by the failure of a small but significant number of agencies
involved in these cases to meet the needs of those who have been bereaved by tragedy. This
guidance will give NHS organisations the confidence to approach families openly and to engage
them meaningfully in what is a complex and difficult process for everyone involved.”

Ben Thomas, Head of Mental Health and Learning Disabilities at the NPSA said: “The
Independent investigation of serious patient safety incidents in mental health services good
practice guidance is a practical resource, in particular for those who are faced with responding for
the first time to such an incident. Dealing with the aftermath of a serious incident can be a
daunting task for all involved and the guidance aims to help conducting independent
investigations in a timely, co-ordinated and robust fashion as systematic as possible.”

The document has been drawn up in consultation with the Department of Health, Healthcare
Commission, Strategic Health Authorities, mental health trusts and The Zito Trust.

             Full report
Mental patients abscond, Hackney Gazette, 14th March 2008
An investigation is under way into how three mentally ill patients have absconded from hospital in
just three weeks. Olubusayo Okanlowan, Alexander Jelley and Henry Whitfield were all detained
under the Mental Health Act. But the three men ran away from their carers while on escorted
leave from psychiatric wings in Hackney. Mr Whitfield was being held in a medium secure unit at
the John Howard Centre in Kenworthy Road, Homerton. The 47-year-old went missing while out
with a carer on Friday and has not been seen since. Police have advised members of the public
not to approach Mr Whitfield and to call 999 immediately. "Although he is believed to be quite well
at this point in time, concern has been expressed he may deteriorate if he does not return," said a
Hackney Police spokeswoman.

The other two men are patients at the City & Hackney Centre for Mental Health in Homerton Row.
Okanlowan, 41, also known as Teddy, absconded on February 19 whilst on a trip away from
hospital. A police spokeswoman said Okanlowan had been sectioned three weeks ago but was
not a risk to others. She added: "There is concern because he is vulnerable and will be
deteriorating without his medication." The third patient Jelley absconded whilst on escorted leave
last Monday, but returned a few days later.

The mental health charity, the Jonathan Zito Trust, has called for a "systematic review" of patient
leave. The City & Hackney Centre for Mental Health is based in the East Wing of the Homerton
Hospital but run by the East London NHS Foundation Trust. A spokeswoman for the trust
confirmed an internal investigation has been launched.

Inquiry over murder of Father Bennett, Western Mail, 14th March 2008
A health watchdog is to look into events surrounding the death of a priest who was stabbed to
death by a mentally-ill man who believed he was the anti-Christ. Father Paul Bennett, who was
profoundly deaf, was killed by Geraint Evans outside the vicarage at St Fagan’s Church,
Trecynon, Aberdare, on March 14 last year. Parishioners will gather in Trecynon today FRI to
attend a memorial service for Father Bennett on the first anniversary of his death.
Evans, 24, who lived in a flat overlooking the vicarage and had written his plans for the killing on
his computer, pleaded guilty last October to manslaughter on the basis of diminished

Cardiff Crown Court heard Evans suffered from paranoid schizophrenia and a personality
disorder, and had used cannabis and inhaled lighter fuel since his early teens. He had never
been under the care of psychiatric services until his arrest for the killing, however. At the
sentencing, David Aubrey QC, defending, said, “This was brewing inside the defendant. Some
people may have been aware of features of his condition, but little if anything was ever done. One
can only wonder what would have been the result if anyone had done something earlier in his
The inquiry, ordered by the Welsh Assembly Government and conducted by Health Inspectorate
Wales, is understood to be looking into the reasons why Evans was not known to mental health
services. It is expected to examine the care Evans received and the events leading up to the
killing. A WAG spokesman yesterday, “The Welsh Assembly Government has confirmed that an
independent external review into the homicide of Father Paul Bennett is under way and will report
later this year.”

A spokeswoman for Healthcare Inspectorate Wales said, “We have been asked to undertake a
review by the Minister for Health and Social Services.” “As we are currently part way through the
investigation we have no further comments to make at this point.” News of an inquiry will come as
some comfort to the family of Father Bennett after they demanded answers following Evans’s
Julie Hanchet, the cousin of Father Bennett’s widow Georgina, said at the time, “Someone must
have known how disturbed this man was and could have intervened. Where were the mental
health services? We need to know where the failings have been. We ask that an inquiry is called
and persons be held accountable. Our family needs answers. This was a premeditated, planned
and savage attack. We feel that the legal system has failed Paul and ourselves.”

The investigation was welcomed by the Archbishop of Wales, Dr Barry Morgan. He said, “Geraint
Evans, who was convicted of the manslaughter of Father Paul, was suffering from paranoid
schizophrenia while living in the community of Trecynon. I am very grateful to the Welsh
Assembly Government and to the Minister for Health and Social Services for agreeing to review
mental health services in Rhondda Cynon Taf and for the ready co-operation of the county
council in that review.”

A spokeswoman for the Church in Wales said Father Bennett’s family had requested the
memorial service at St Fagan’s Church at 7pm is a “quiet occasion for parishioners only”. Dr
Morgan said, “It has been a very difficult year for the parish and it’s going to take a long time for it
to recover from such a tragedy. “The thoughts and prayers of the whole church will be with the
family as they face this painful anniversary.”

Inquiry underway as health unit patient is restrained in pub, Gloucestershire Gazette, 18th
March 2008
A second investigation is under way at a Pilning mental health unit following an incident when a
patient "went beserk" in a pub. Drinkers and Sunday lunch customers at the Plough Inn were
alarmed as pub staff struggled to restrain the patient from the nearby Hayes Hospital, a unit for
people with autism-related conditions including Asperger Syndrome, who are detained under the
Mental Health Act.

Landlord Shaun Lawley, 42, suffered bruising as he wrestled with the man who was visiting the
pub with a carer.
Witnesses said trouble began when the patient began pestering people, grabbing one female
customer by the arm.
Mr Lawley's partner, Sue Chance, said the man "flipped" after being warned to behave. "He just
went beserk and started hurling glasses, vases and a charity collection box at Shaun. He was
throwing things at his face. The police arrived quickly and thankfully no one was seriously hurt,
but it was very frightening for everyone, customers and staff alike, and Shaun was lucky his
injuries weren't worse. Shaun and four police officers had to hold the man down while staff from
the unit came to collect him. Damage to the pub runs to at least £200 and we also had to refund
customers whose visit was ruined. It was a real ordeal." Ms Chance said the man had visited the
pub with his carers previously without incident. An Avon and Somerset police spokesman said the
man had already been removed from the pub when officers arrived, but officers had to subdue
him in the car park before escorting him back to the unit. Police would be taking no further action
and any further investigations would be carried out internally at the unit.

A spokesman for the National Autistic Society, which runs the 12-bed unit, funded by the NHS,
said the man's care programme was being reviewed to ensure he was getting the right level of
support. "The individual involved, accompanied by a member of staff, was visiting the pub as part
their regular weekly routine," she said. "Staff members from The Hayes visited the pub on
Monday to apologise and offer payment for damage caused." She said that although the unit had
enhanced staffing levels, a fence and was locked at night, it was officially classed as low security.
"Service users do visit the local community but they are all risk assessed and are accompanied
by a carer," said the spokesman.
* Officials at the hospital last month sought to reassure the community following an incident when
a patient escaped and was subsequently arrested in Wales and charged with the double rape of a
schoolgirl in Chepstow. The 20-year-old man has since appeared at Newport Crown Court and is
currently remanded in custody until his next appearance on April 25.

   Inquests, Suicide, Suicide Prevention, Euthanasia and associated legal

Jury returns critical verdict at the inquest of mentally ill man, Community Care, 4th March
The inquest in to the death of Adrian Coldwell in police custody has identified several failures.
Coldwell, who had mental health problems and a history of self-harm and suicide attempts,
hanged himself with the cord from his tracksuit bottoms in a cell at Pontefract Police Station in
West Yorkshire in December 2004. On two previous occasions, Coldwell had been arrested and
kept under policy custody, as a place of safety, under the Mental Health Act.

In a critical narrative verdict, the jury said the police failed to have a doctor examine Coldwell and
proceeded to give him medication without a doctor’s direct supervision. It also found the police
had given unsatisfactory levels of supervision and checks, before and after he was given
medication, and had failed to act upon warnings over Coldwell’s tracksuit bottom cord. The jury
identified a further failure whereby the policy had not brought up Coldwell’s previous custody
records because they had mistyped his surname.

However, Ruth Bundey, the INQUEST solicitor representing Coldwell’s sister, Jane Sharp, said:
“Ironically, the very custody sergeant on whose watch Adrian died had admitted him to the police
station three months before his death, after he had attempted suicide with a pipe attached to his
car exhaust.” Sharp added: “My brother should never have died. He should never have had a
Class A drug, morphine sulphate, given to him by a PC while in custody, without a medical
examination. I think the dosage he received scrambled his mind.”

Tragic death of mum terrified of living on own, Burnley Express, 5th March 2008
A depressed Burnley woman, who was terrified of living on her own, died from an accidental
overdose, an inquest heard. Mrs Mary Brooks (48) was found dead at her home in Forest Street
with a packet of pills in her bag. Her sister, Mrs Ann Fawcett, told East Lancashire Coroner Mr
Richard Taylor Mary started with depression in 1978 after giving birth to her daughter. Mrs
Fawcett said: "She had suffered for decades and was constantly in and out of hospital with
mental health related issues." She went on: "She became more and more institutionalised and
eventually left her husband before going to Halfway House in about 1993 which provided her with
a controlled programme of help. This gave her very little independence."

In 2005, alternative accommodation for Mrs Brooks was arranged at a house in Talbot Street and
she was found a home in Forest Street, in 2007. Mrs Fawcett added: "She was not prepared to
go back into the community. The area was very run down and her condition started to deteriorate
very quickly. She was definitely not ready for life after Halfway House. She has tried taking an
overdose before which I think was a major cry for help. She used to get very frightened at night
and struggled to take control of her new life and her new found independence."

Pathologist Dr Abdul Al-Dawoud said he found two types of drug in her system at a toxic level
which would have affected the brain and heart. It was the combination of the drugs, fluoxetine
and zolpiden, that proved fatal.
Mr Taylor said: "I see a very frightened young lady who was miserable, depressed and found life
very difficult. It appears she has got muddled up with the amount of medication she had taken on
the night of her death as she did not have a proper prescription. There is certainly no evidence to
prove she has taken her own life." Mr Taylor recorded a verdict of accidental death.

Death of woman in prison down to Styal's lack of resources, Community Care, 11th March
Under-resourced mental health services and insufficient inter-departmental communication at
HMP Styal led to the accidental death of inmate Valerie Hayes, a jury found last week. The
inquest into the death of Hayes heard that mental health services at the prison were “seriously
under-resourced” leaving staff incapable of doing their jobs properly. Hayes, who was on suicide
watch at the time of her death and who had a history of drug use, mental health problems and
self harm, was found hanging in the Care, Support and Reintegration Unit; a segregation unit
used to discipline inmates and to house those who needed extra support. On the day of her
death, staff failed to remove a mattress cover used by Hayes to hang herself with; even though
she was seen earlier that day ripping the cover up in her cell.

Deborah Coles, co-director of INQUEST, a non-governmental legal organisation, said: “What this
verdict demonstrates yet again is that the prison system is neither adequately resourced nor
adequately managed in order to ensure the safety of the women in its care. Urgent action is
needed to divert mentally ill women out of prisons which are incapable of meeting their complex
needs.” Since 2002, nine women have killed themselves while remanded or convicted at HMP
Styal, of whom six died in 2002-3. Although the government published a review of vulnerable
women in prison last March, in response to an earlier investigation into HMP Styal, it has not
allocated resources to take forward the review’s recommendations.

Cannabis-smoking mum stabbed herself to death, The Argus, 11th March 2008
A mother driven insane by cannabis stabbed herself repeatedly through the chest with a carving
knife after claiming she was spoken to by a dog. Julie Cross told friends the animal was "trying to
tell her something" before picking up the 5in blade and ramming it at least five times into her
chest and abdomen. An inquest was told the former receptionist, from Goring, used speed and
cannabis on a daily basis and in the weeks running up to her death had slashed her wrists and
smeared her blood across a crucifix and also hung a noose from her attic. Katie Leason,
spokeswoman for mental health charity Rethink, said the case further proved that cannabis
causes severe mental illness. "We don't believe there is any doubt about it now. There is a
proven link between the drug and psychosis," said Ms Leason.

Rhys Cotton, 20, who lived with Miss Cross and her son Terry Greenslade, 22, discovered her
body slumped on the floor on the morning of June 27 last year, after his blood-stained dogs ran to
alert him as he got out of the bath. Ms Cross, 41, suffered three fatal puncture wounds to her
lungs and liver, the deepest of which was 4in long with other minor superficial knife injuries. Mr
Cotton, who called Miss Cross his "auntie", was the only person in the house at the time of the
tragedy and was arrested the same day on suspicion of murder but later released. He said during
a police interview, which was read at the inquest: "I went upstairs and could see into her
bedroom. "She said to me, 'I think the dog is trying to tell me something.' "I thought that was quite
strange. A lot of things she did I found strange, but didn't really think too much about it." He
added: "She would tell me that she regularly heard voices and would often trash the house."

The hearing, at Worthing Town Hall, was told that Miss Cross, from Limbrick Lane, had drug-
induced psychosis diagnosed in 2006. It had led to her spending much of her last year in and out
of the Mill View psychiatric hospital. The inquest heard that during what was described as a "very
difficult life" Miss Cross had made repeated attempts on her own life, starting at the age of 14.
She had suffered two acrimonious divorces and on one occasion a spurned husband had
returned to the family home with a can of petrol and a lighter, threatening to firebomb the

Detective Chief Inspector Steve Johns released Mr Cotton after he gave a "full and plausible"
account of the incident. That, coupled with Miss Cross's history and an absence of evidence of
other third-party involvement, led the detective to conclude the wounds were self-inflicted.

Pathologist Dr Robert Chapman, who carried out a post-mortem examination on Miss Cross,
agreed. He told the inquest: "There were a number of factors which allow us to make a judgment
that is consistent with self-inflicted injuries." Asked if Miss Cross would have been strong enough
and capable enough of repeatedly stabbing herself, Dr Chapman said: "I think somebody would
be capable of doing this. The major wound would not have instantly disabled her."

The coroner recorded a verdict of misadventure, saying the wounds could have been a "cry for
help". Miss Cross' family and friends told The Argus they believe she was murdered and would
not have been able to inflict the wounds. After the hearing, Amanda Cross, her sister, said: "She
hated violence and adored Terry. She wouldn't have taken her own life. We are not going to let
this drop."

Woman, 38, fell to her death from cliff-top, Cornish Guardian, 12th March 2008
A St Austell woman plagued by the delusion she had been abused as a child fell to her death
from cliffs above Porthpean Beach, an inquest heard. Shirley Jane Andrew, 38, was found dead
on Porthpean beach at around 1.30pm on the afternoon of July 17 last year. An inquest in Truro
heard Miss Andrew, who was known by her middle name of Jane, found "the outside world very
difficult" after leaving Poltair School. Her sister, Jeanette Poulton, told the inquest: "As a child
Jane was bright, shy and gentle. She attended Poltair School but on leaving found the demands
of the outside world very difficult. She struggled to maintain a social group and hold down

Jane's mother, Monica Andrew, said: "She visited me daily. Although she was only supposed to
come for three hours a day, I relented out of a motherly instinct and she stayed longer. I knew
she only wanted to hide from the world. On July 16 she left my house in her car at around 5pm.
Later that night, around 10pm, I heard the front door rattling. It was Jane and she was saying: 'I
only want to talk.' I told her I was worn out. She wanted to move back in but I wanted her to stand
on her own two feet." The following morning Jane called mental health services before making
her way to cliffs by Porthpean and falling to her death.

Dr Daniel Lang told how his patient, who also worked at the practice as a cleaner, had suffered
"acute" mental problems as of January 2007. Her psychiatric nurse, Francis Byrne, explained that
Jane suffered a psychotic fixation about her mother. He added: "Jane had delusional beliefs. She
believed that she had been in prison, and that she had threatened people with a knife." He said at
times his patient "remained adamant" that she had been abused.

Det Sgt David Ford of St Austell CID investigated the tragedy. He said that after a detailed
examination of the cliff-top from which the victim fell, he felt "it was possible, although there is no
evidence, this was a deliberate fall". Recording an open verdict, coroner Dr Emma Carlyon said:
"It's not clear how or why she fell from the cliff." After the inquest Mrs Poulton said: "Jane was a
shy and happy girl. She was very well-read, she enjoyed her own company, and it was only very
lately that anything was wrong with her."
Lifting gear for funeral of 52st man, Cornish Guardian, 14th March 2008
Lifting gear is being brought in to lower the body of a 52-stone man into a grave, a council has
said. John Christian Jeffrey, 29, was found dead in his room by a support worker at Trenchard
Park Gardens hostel in Norton Fitzwarren, near Taunton, Somerset, on February 28. As he has
no relatives, the cost of today's funeral is being borne by Taunton Deane Borough Council. And
as funeral directors had to order a custom-built extra-large coffin for the ceremony, the occasion
is set to cost the council £800.

Staff at the hostel, which caters for people with drug, drink or mental health problems, said Mr
Jeffrey was referred there by the council. A member of staff, who asked not to be named, said:
"He was a big chap, I only saw him once. It's incredibly sad to turn round and find that you don't
have anybody in the world."

John Eaton, a registered mental health nurse, who runs Trenchard Park Gardens, is expected to
attend a private graveside service at St James Cemetery, on Staplegrove Road, Taunton, this
morning. Funeral director Nigel Ford will run the service and said it was quite a common
occurrence for a funeral to take place where there were no known relatives. "It's very sad," he
said. "We've had to make a coffin specially for the man as he was quite large. In countries where
people are larger, like America, I expect it's not too unusual, but we don't get many." An inquest
was opened at Taunton Coroner's Court, and the cause of death is being investigated, although it
is believed to be natural causes.

Millbrook patient died hours after being released, Mansfield Chad, 19th March 2008
Health chiefs have vowed to investigate how a patient at Sutton's Millbrook psychiatric unit was
allowed to leave the centre just hours before he was found dead at Mansfield Bus Station. Their
pledge comes after it emerged staff 'not suitably qualified' had given Mansfield drug addict Mark
Salisbury permission to attend a probation meeting on 12th September last year. He was
discovered slumped on the floor of a toilet cubicle at the bus station later that day with a
tourniquet, needles and syringes next to him. The 29-year-old's death from the 'tragic' heroin
overdose happened just a day after he had been admitted to hospital after a previous overdose.

But an inquest into his death on Thursday was told how the psychiatrist and senior house officer
at Millbrook were not informed of his first overdose –– and were not consulted the next day when
nurses allowed him to attend his probation meeting after a visit from police. In recording a verdict
of accidental death, Nottinghamshire coroner Dr Nigel Chapman said he was concerned the
decision to allow Mr Salisbury to leave the premises had been taken by staff 'not suitably
qualified'. "This is a tragic accident where he has bought some heroin and injected himself above
what he had been used to at this time," he said. "Granted, he needed to leave the hospital to get
his money and to visit probation, but he had smoked heroin which made him collapse and had to
be taken to Accident and Emergency. The medical staff were unaware of this the following
morning and the decisions were all made by nurses, such as whether he should see probation,
who are not suitably qualified for this. We do not know whether this would have made a difference
in the long run, but there are a number of things that the medical staff should go away and think

Nottinghamshire Healthcare, which runs Millbrook, says it is aware of the coroner's concerns,
with a spokesman telling Chad: "We are taking those concerns very seriously and will undertake
a full internal investigation at a senior level and will act on any findings. Our sympathies are with
Mr Salisbury's family and friends." The inquest was told Mr Salisbury had died three weeks after
being admitted to Millbrook following numerous psychotic episodes - where he was sectioned
under the Mental Health Act while further assessments were carried out.

But staff at the unit said they believed Mr Salisbury was making good progress due to his
determination to stay off drugs and because he was experiencing fewer psychotic episodes. He
was therefore allowed to leave the unit's grounds for two hours a day to collect his benefits and
visit the probation service. The inquest was told Mr Salisbury had been good at informing staff
when he was going out, while he also attended his appointments regularly. But when he did not
turn up for his appointment on the day he died, the unit contacted police, who confirmed that Mr
Salisbury had been found. His body was identified by two nurses.

Father of four fell from cliff in St Ives, Cornish Guardian, 20th March 2008
A father of four from St Ives fell to his death just hours after phoning social services to tell them
he needed to be sectioned, an inquest heard. Brendan Cullen rang his mental health team with
the message on September 20 last year. But a receptionist at Camborne Mental Health Team
told him his social worker was "in a meeting". Instead she told the 41-year-old she would pass a
message on so they could ring him back. Social worker David Wilmot told the inquest in Truro he
received his secretary's message "later in the day", by which time his client had died. The inquest
heard Mr Cullen fell from cliffs into the sea at Hawkes Point, near St Ives. His body was spotted in
the water off Porth Kidney by a holidaymaker. Mr Cullen had suffered mounting paranoia in the
days before his death.

His St Ives GP, Dr Christopher Anthony, told the court he referred Mr Cullen to David Wilmot two
days before his patient's death. Mr Cullen's partner recalled how events unfolded in the days
before his tragic death. She said: "On September 17 Brendan said he was feeling sick. He said
he felt unsafe in Cornwall and people were trying to kill him. We went to St Ives Surgery and
while waiting outside Brendan suffered a panic attack. Brendan felt he was about to be sectioned
and he wanted to go back to London. When Brendan went to see Dr Anthony, the doctor told him
he would make contact with the mental health team. I expected Brendan to be sectioned that day.
His demeanour was extremely aggravated. Brendan wanted someone to come and take him to a
mental health unit - but no care plan was put in place."

Coroner for Cornwall Dr Emma Carlyon recorded an open verdict. She said: "Brendan was last
seen walking the coastal footpath to Lelant. No-one saw how he came to be in the water but a
mobile phone was found with the message 'Rebecca I'm so sorry'. It is possible he intended to
jump from the cliff. He had been suffering from extreme agitation and depression and had phoned
the mental health team asking to be sectioned. It is not clear how he came to be in the water."

Woman died 'a natural death', This is Gloucestershire, 20th March 2008
Cheltenham woman Valerie Darby died a natural but unascertained death, a Gloucestershire
coroner ruled yesterday. The inquest heard how the 64-year-old's body was badly decomposed
when she was found dead at her home on April 16 last year - making establishing an exact cause
difficult. Mother of two Mrs Darby had a long history of chronic mental illness and had been
sectioned under the Mental Health Act several times in her lifetime, the court in Cirencester
heard. She was found dead last April by PC Kyle Murphy and colleagues at Durham Close, who
went to check on her welfare at that address. PC Murphy said he recognised the dead lady on the
bed - because he had met her when she was being evicted from the address two months earlier
in February. There were no suspicious circumstances surrounding the death, the court heard.

Dr Richard Bryan, who performed a post mortem, said her death could have occurred several
weeks and up to two months before she was found. No drugs were found in her system and no
evidence of trauma but severe coronary atheroma was discovered, he said. He told the coroner
that this coronary condition was serious enough, if he had found it in body in a better state - to
have caused death.

Consultant psychiatrist Dr Gillian Bluck said Mrs Darby was not known to her personally, but she
had compiled a report from the files. Her psychiatric history dated back to 1965, she said, and
she was first admitted to hospital with mental problems in 1972. Then things eased, but problems
continued and she was started on anti-depressants in 1994 and over the next few years, her
behaviour was characterised by delusion and outbursts, the doctor told the court. In April 2002,
she was detained under the Mental Health Act and admitted several times more under the act
after that. Latterly, she had become increasingly resistant to help, medication and services,
added Dr Bluck.

Gloucestershire coroner Alan Crickmore said that Mrs Darby had been found dead at her home -
from which she had been evicted in February last year. Previously, he said, there had been
attempts made by social and psychiatric services to make contact but she had a long history of
disengagement. Mr Crickmore said it was "more likely than not" that she had died of a sudden
death from coronary artery disease but said he would record a verdict that she died a "natural
death but unascertained causes."

Open verdict at inquest into Chester drowning victim, Chester Evening Leader, 21st March
An artist and gardener from Chester drowned after falling into the River Dee, an inquest heard
yesterday. The body of Maurice Jones, of Circular Drive, Lache, was recovered near the Holt-
Farndon bridge on Sunday, November 25. In recording an open verdict North Wales Coroner
John Hughes said no evidence existed to suggest the 66-year-old had taken his own life. Kenneth
Jones, a retired accounts manager, revealed his brother had been badly affected by the death of
their mother in 2002, and had written numerous letters to the NHS and Care Ombudsman
complaining about the way she had been treated in hospital. He had also been left traumatised by
the death of his father, in 1962, who died after suffering a heart attack while out sailing with his
son in West Kirby. The brothers had fallen out of contact after 2002 as Maurice, who was
unmarried, became more reclusive.

The inquest was told, however, that Maurice had remained a common sight in Lache, taking his
bike out early in the morning and not returning until late in the evening. His body was found by a
group of three brothers and their friend, all from Mold, who had been sailing along the Dee on a
pleasure cruiser. Police were informed and Mr Jones was identified by his keys and a shopping
list, which matched handwriting found at his home. The hearing was told that Mr Jones had
studied at the Royal Horticultural Society's college in Wisley, Surrey, before he moved to Africa to
carry out volunteer work on behalf of Save The Children. He may have been in the Holt area
because of its river flowers, said Mr Hughes.

He said that a post mortem examination had shown evidence of significant cardiac disease which
may have caused a collapse, although this was not certain. Delivering an open verdict he said:
"One of the most difficult areas of determination for a coroner is deaths in water because you
need some sort of unequivocal evidence to give a chance of delivering an authoritative verdict.
The one thing that I will say is that I have no evidence that he did a deliberate act to take his own
life. I know his doctor was worried about his patient's mental health but I'm convinced this was not
a suicide. In those circumstances I am going to return an open verdict. Even on the balance of
probabilities I don't know what happened."

Drugs death of doting mother, The Argus, 26th March 2008
A doting mother who had a history of depression died after taking a cocktail of prescription drugs
and alcohol. Denise Rose Hemsley, 41, was found dead at her home in Beauford Road, Horam,
on April 13 last year. At the inquest into her death in Eastbourne, East Sussex Coroner Alan
Craze read a toxicology report which found the former garage attendant had taken sleeping drugs
tramadol and temazipam, and drunk enough alcohol to be more than three times over the legal
drink-drive limit. The inquest heard that Mrs Hemsley, a mother of two who was separated from
her husband and whose teenage boys were at the time being looked after by her mother Jean
Wickham, had previously taken several overdoses of prescription drugs. Mrs Wickham, of The
Rise, Horam, described these as "cries for help". The inquest heard Mrs Hemsley was upset at
having been beaten up two weeks before she died and still had a black eye from the attack. She
was found dead lying curled up on her bedroom floor. Police officers found empty drug packets
throughout the house and an almost empty bottle of vodka in a drinks cabinet.

Speaking as a witness at the hearing, Mrs Wickham said she had asked doctors on several
occasions to stop prescribing her daughter drugs when she was taking them in bulk. She said the
doctors told her they had reduced the number of tablets Mrs Hemsley was prescribed each time
to try to prevent an overdose happening. Mrs Wickham said she had also asked the mental
health team dealing with her daughter to section her under the Mental Health Act for her
daughter's own protection but to no avail. Recording a verdict of death by misadventure, Mr
Craze said: "This is a possible suicide because it all depends on what was going through her
mind when she did it. I don't think it's possible to say beyond reasonable doubt that she wanted to
kill herself." He said it was a shame that Mrs Hemsley had not made more use of the medical and
emotional support that had been offered to her by various agencies. Speaking after the hearing,
Mrs Wickham said her daughter was a character who "liked to have a laugh". She added: "She
loved her two boys and she loved life."

Man cut throat in store, This is Cornwall, 29th March 2008
An open verdict has been returned at the inquest of a man who cut his own throat in a busy high
street store. Russell Ward, 27, died after using a craft knife to slash himself in Woolworths'
Penzance branch in September 2007. The inquest heard Mr Ward was being treated for mental
health issues at the time and his medication had been changed. Cornwall County Coroner Dr
Emma Carlyon said the evidence was not clear enough to warrant the legal standard of proof for
suicide. The hearing, held at Truro City Hall, was told how, for several years, Mr Ward had
undergone treatment for mental health problems and his medication had been changed two
weeks before his death. When the incident happened, staff managed to guide families away from
Mr Ward and out of the store. They tried to reason with him and called 999. Shortly after his
death, father Colin Ward said: "Our son was a very loving, generous and gentle little soul, and will
always be remembered as such by his friends and family. Unfortunately, he was also plagued by
disabling levels of anxiety, which ultimately overwhelmed him. As a family, we must remember
him for his life, and not his passing."

Bridge jumper suffered from schizophrenia, This is Hampshire, 30th March 2008
A Southampton man who plunged to his death from the Itchen Bridge suffered from paranoid
schizophrenia, an inquest heard. Southampton Coroner's Court heard Michael Pilcher had
suffered from the psychosis since 2004. The 26-year-old, of Newton Road, Bitterne Park, was
killed instantly when he jumped from the bridge on January 24.
Deputy coroner Gordon Denson recorded a verdict of suicide.

Young black men are at higher risk of suicide than their white counterparts, EurekAlert,
31st March 2008
A study examining suicide rates and pre-suicide clinical symptoms in people from different ethnic
groups, has found that rates of suicide vary between ethnic groups with young black men aged
13 to 24 at highest risk. The research, published in the medical journal Psychiatric Services,
suggests that symptoms traditionally associated with suicide are less common among some
ethnic groups, and cannot be relied upon for predicting suicide. Led by Kam Bhui, Professor of
Cultural Psychiatry and Epidemiology at Barts and The London School of Medicine and Dentistry,
the study looked at the four largest ethnic groups in England and Wales – black Caribbean; black
African; South Asian (Indian, Pakistani and Bangladeshi), and white. A comparison between
ethnic groups was made of the symptoms that clinicians consider increase the risk of suicide:
suicidal ideas, delusions and hallucinations, depressive symptoms, deliberate self-harm,
emotional distress, hopelessness, and hostility.

Researchers examined data from the National Confidential Inquiry (NCI), which receives data on
all potential suicides from the United Kingdom’s Office of National Statistics, and investigates
suicides within 12 months of contact with mental health services in England and Wales. The black
African and black Caribbean people who committed suicide suffered from high levels of delusions
and hallucinations and deliberate self-harm, but had low rates of other clinical indicators of
suicide at the last contact they had with a mental health services professional. Schizophrenia is
the most common diagnosis among black Africans and black Caribbeans who commit suicide,
and they are less likely to have suicidal ideas and depression than the other groups.

South Asian people who committed suicide had high levels of hopelessness, psychotic
symptoms, and depression, but low levels of suicidal thoughts compared with the white group.
Immediate risk of suicide was perceived to be highest among white people. Suicides within 24
hours of professional contact were most often reported among black Caribbeans, and suicide
within one to seven days was most commonly found among black Africans.

The study found high levels of suicide among black African and black Caribbean men aged 13 to
24, living in England and Wales. Clinicians reported that suicide was preventable in 31 per cent of
black Caribbeans who committed suicide, and in 18 per cent of South Asians who committed
suicide. The findings offer advice for future strategies and research to prevent suicides. Professor
Bhui said: “Suicide is proportionally more common among young black African and black
Caribbean men. Untreated psychosis and ethnic differences in symptoms that usually predict
suicide may explain these findings, especially the suggestion by clinicians that a third of suicide in
the black Caribbean group were preventable. These findings argue for a more mature and
informed cultural study of suicide and self harm, alongside more effective engagement and
culturally appropriate interventions.”

Excerpts reprintedwith permission from the monthly e-bulletin compiled by Dave
Sheppard Associates :

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