Happy Endings, Three forensic case studies

P Grahame Woolf FRCPsych

Retirement is a time when the old tend to reminisce, and members of the Society of Clinical Psychiatrists, which is independent, informal and seeks to be complementary to the Royal College of Psychiatrists, may  welcome the opportunity to share experiences of particular interest. 

These three cases from the '70s & '80s are linked by their successful outcomes, reached by unusual routes, and succeeded gratifyingly and against the odds.

Northern Irish juvenile homicide

My interest in the issue of borderline diminished responsibility was fired by experience as an expert witness in a murder case involving the late Dr Peter Scott, at that time chairman of the Royal College's Forensic Psychiatry Committee in which I then served. 

A young man from Northern Ireland, sent away from the troubles to live with relations in London, bought a gun in a pub, with the purpose to kill his sister's husband, who had been giving her a hard time.  He was charged with murder and the prospects of a successful defence were unpropitious. 

I built up a case from a " combination package" of factors which, in totality, might meet the criterion for diminished responsibility, although none was sufficient on its own.  Crucially, I suggested that, having been brought up in Northern Ireland in the midst of sectarian violence, he had not yet attained a mature regard for the "sanctity of life", and that this constituted "a significant abnormality - - -  amounting to an incomplete development of the moral aspects of mind". 

The prosecution, unsurprisingly, was not prepared to accept that reasoning but the lawyers encouraged a pre-trial conference with Dr Scott, the Crown's expert, with the aim of trying to agree the psychiatric evidence.  Peter Scott met me cordially, disagreed that these factors sufficed for a Section 2 defence, but wished me luck!  We both gave evidence accordingly, I a novice, he a renowned leading Expert. 

The jury preferred my formulation and, with their verdict having freed his hands from a mandatory life sentence, the judge sentenced him to 3 yrs. imprisonment for manslaughter, with a prospect of very early parole.  Many years afterwards I was gratified to hear that case cited by Susanne Dell in a lecture to the Royal College of Psychiatrists about anomalies resulting from s2, which still exists only to provide a means of escape from the mandatory penalty for murder.  

Year after year, recommendations continue to be made that this situation should be brought to a halt.

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Moebius Syndrome and arson

My second case illustrates the risks of appearing before a less than open-minded judge.  A 22 yr. old man, with a bizarre appearance caused by congenital facial diplegia (Moebius' syndrome), appeared before the Crown Court charged with arson.  No association between criminality and that rare condition had been reported, nor was any treatment described in the literature.

He grew up slow of speech and thought, and his problems had affected his childhood and school attendance adversely.  He had complete bilateral paralysis of the facial and ocular nerves, so that expressive movements of the face were absent and the whole head had to be turned to see to left or right.  He had an unusually repellent facial appearance, generally immobile and expressionless, with frequent jerky sideways head movements and his eyes remained wide open, even when he was sleeping.  He was unable to smile and could not move his cheeks to reflect changing moods.  He had too a club foot, a recognised associated defect.

Suffering teasing at school, the advice received was to try to weather the storms and survive in a normal world.  He completed secondary school, began work as an apprentice cook and became a competent swimmer and skater.  He had a happy time living in Cornwall, accepted as a person in his own right by the surfing fraternity. 

At 20 he took up residential catering work in a hospital, with accommodation in the nurses' home, where he encountered teasing and ostracism, more cruel and sustained than he had ever experienced before.  His personal life was unhappy, and he failed to make more than transient contacts with the young women living in the home before being crudely and suddenly rejected.  He received obscene anonymous postcards and became a general laughing stock, but did not confide this unhappiness to his parents. 

In the nurses' home he had to share washing facilities with young women with whom he had failed to make headway, and the room in which they dried their uniforms and underwear became a focus for his fantasies and discontent, and preyed upon his mind.  On several occasions he burnt and damaged clothing in the laundry room and rubbish nearby.  No one was injured, and the total cost of repairs was less than £300. 

At his trial for arson and criminal damage, with no previous forensic record, the probation report explained how this young man was "someone who would inevitably arouse feelings of dislike, had been deeply hurt at various times and was constantly harassed at the hospital.  Although his feelings were always bottled up, he laughed and cried in his inner person without having the relief of a normal outward expression".  The probation officer recommended a probation order to help him come to terms with his guilt, and to examine ways to express his feelings without allowing them a form of expression which could result in harm to others. 

Bailed to live at home with his parents, he worked successfully as a butcher.  My psychiatric report for the defence recommended probation with a condition of psychiatric treatment.  It stressed that the fires had been confined to the unhappy period during which he lived in the hospital nurses' home, and that there was no suggestion of seriously disturbed behaviour elsewhere or at other times.  The disclosures of his problems to police and parents, followed by discussions with professional people, had relieved the tension sufficiently to make recurrence improbable.  He recognised the need for further support and treatment for natural feelings of guilt and remorse and promised full co-operation with whatever might be advised. 

Avoidance of imprisonment was urged because of probable victimisation by other inmates and because of likely deleterious effects upon his chances of future rehabilitation.  Because of the complexities of the case an application was made for an examination by Dr Peter Scott, the eminent Maudsley Hospital and Home Office forensic psychiatrist (q.v. the first case reported above).  But a judge of the High Court refused this application, and the case was speedily put into the lists, before an outpatient clinic appointment had been achieved.  

I was present in court, but as matters proceeded it appeared to those representing him that it might be counter-productive to call me to give oral evidence, psychiatric evidence being then still suspect in some of our courts.  Mr Justice Melford Stevenson, when sentencing, said that he had read attentively the probation report and "had also read with equal care the psychiatrist's report which purports to explain your physical difficulties and your mental difficulties - - I do not doubt that everyone who commits a series of offences of this kind can be made the subject of the kind of report that has been devoted to your case - - -  responsibility for the interests of the innocent members of the public who suffer is left to the Court - - -  the form in which I discharge it is designed to discourage others tempted to indulge in a similar course of conduct".  He sentenced him to 4 years imprisonment at this first ever court appearance.

After Judge Melford Stevenson died, the press regaled readers with his caustic witticisms, and it was said that his "savage sentencing" was often out of line with guidance from the Court of Appeal, which had stressed, not long before, that in cases of arson it was wise to call for a psychiatrist's report and unwise to sentence without one. 

Possibly the then new liberal attitude towards the granting of bail went against the interests of this Moebius syndrome victim.  Had he been remanded in custody (even without the court having called for a psychiatric report) the medical officer would surely have picked out this very unusual case and arranged for a prison psychiatrist's report, which might have influenced the court and helped to prepare the ground for a hospital disposal?

Following refusal of leave to appeal against sentence, information was not readily available as to the risk that the total duration of imprisonment might be lengthened as a consequence of renewal of the application before three judges.  The young man decided to abandon his appeal.  He had been strongly discouraged through the influence of a cellmate whose recent appeal had failed, with the addition of the time awaiting appeal to his period of imprisonment.  He also took into account the financial burden, which might have been placed upon his parents, because legal aid at this stage would no longer be available.

The twist in this story is that his subsequent progress illustrated the opposite poles of the possible effects upon a vulnerable individual of imprisonment in Great Britain at that time.  At first he was depressed and became unwell, predictably stigmatised and ridiculed by fellow inmates, tormented by being "locked up 23 hours a day in the company of people with a sick sense of humour". 

But later he was moved into a therapeutic setting in H.M. Prison, Wormwood Scrubs, where he received psychotherapy to help him learn gradually to use his voice and body more to compensate for the lack of facial expression.  Whilst having to adjust to the unaccustomed role of convict, he had for the first time in his life received expert psychiatric treatment for the profound and complex mental effects resulting from the physical stigmata of Moebius' syndrome.  In group therapy he learnt about the guilt he instilled because of his deformity, and emerged as a controlling person who had used his mask to hide his true self.   He became optimistic and began to look forward again to tackling life in the outside world.  Capitalising on the proximity of the famous Hammersmith Postgraduate Hospital, plastic surgery to produce a more animated facial expression was undertaken, with encouraging results which additionally boosted his morale.

It was ironical that, after so successfully striving to come to terms with his deformities during a difficult childhood and adolescence, this young man should not have encountered the full force of stigmatisation until early adulthood and in a hospital of all places.  Goffman (Stigma, 1964) explains how those stigmatised during infancy may manage to get through earlier years with some illusions still left, experiencing systematic exposure during adulthood.  He quotes a cerebral palsy victim who found society mainly kindly 'as long as I was in the protective custody of family life or college schedules and lived without exercising my rights as an adult citizen', before subsequently encountering 'the medieval prejudices and suspicions of the business world ...  employers were shocked that I had the gall to apply for a job'. 

Nurses and other hospital workers have a vocation towards compassion for the sick and handicapped and their training and experience tends to enhance their sensitivity and tolerance in the presence of physical deformity and peculiarities of behaviour.  But these positive attitudes may be applied only to a strictly defined category, the patients, and are maintained in the working situation not without strain.  By staking his claim to a fully normal and independent adult working life within the enclosed residential community of a hospital this Moebius victim set in train, unwittingly, those mechanisms of rejection which in his case led to the unlikely outcome of conviction for arson.  

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Search for treatment

My third case recalls a heroic search (no expenses spared, as was possible in those days!) for the optimum treatment of a 17 yr. old youth of mixed parentage, who had killed his sleeping father by frenzied blows to the head with a crowbar.  Straight after he had done so, he presented himself at the local police station, putting money into a charity collecting box before announcing what he had done. 

At psychiatric interview for a bail application 3 days later he appeared cool and totally lacking in remorse or regret.  He justified having committed patricide as appropriate because of longstanding 'hassle' from his old fashioned father, whom he had long nursed thoughts to kill, 'like anyone would'.  He had fortified himself with drink and drugs before acting.  He believed he deserved bail because it was just before Christmas, and he had 'no notion to kill anyone else'.  On remand in custody he was missing the 'buzz' from alcohol, drugs and glue sniffing, his greatest pleasure in life. 

Medical records disclosed a head injury 3 years earlier, 'completely recovered' after five days in hospital, without any suggestion of significant brain damage.  The patricide was most readily explicable in mainly social terms.  After his brother left home he had found himself in enforced isolation with an incompatible and hated father. 

Assessment did not indicate any substantial mental disorder likely to persuade the prosecution to accept a plea of diminished responsibility and it was considered that attempting to pursue that defence might jeopardise eventual parole, with the risk of his spending longer in prison as a 'diminished' lifer.  The prison psychiatrist cautioned that a positive finding of organic brain abnormality might rebound, and influence adversely parole considerations.  His barristers thought a limited determinate sentence unlikely and anticipated a mandatory life sentence for premeditated murder. 

The solicitor nevertheless decided to pursue investigations. His young client had spent his first 10 years in a Children's Home before coming to live with his father, and had been unconscious for two days after his head injury.  Neuropsychiatric investigation indicated left frontal damage from a significant head injury of a type which might lead to impulsive, aggressive behaviour, amounting to sufficient grounds for a plea of diminished responsibility if that might be to his advantage.  The prison psychiatrist conceded brain damage with personality change, potentiated by drugs and alcohol, but reported that it neither required, nor was susceptible to, medical treatment, so he did not recommend a hospital order. 

A prolonged and fruitless search for assessment in a forensic psychiatry unit followed.  With no evidence of psychotic mental illness, the local forensic psychiatrist related the killing to the intrusive relationship of father and son and the effects of alcohol and drugs abuse, discounting the importance of any brain damage, which would in any case be untreatable.  She was not prepared to make a bed available and counselled against brain damage or psychopathy as stigmatising labels which could delay his parole. 

The regional forensic psychiatrist declined to become directly involved without a positive recommendation from his local forensic colleague. 

An approach to a private psychiatric hospital foundered on the triple grounds of inadequate security, untreatability and refusal of funding by the responsible health authority.  As the trial approached it began to seem that the investigations had been counter-productive, as several experts had warned. 

The plea to manslaughter with diminished responsibility was accepted.  It was put to the court that thorough evaluation would not be practicable in prison, and that a hospital assessment followed by treatment for a limited period would assist in determining the likely response to a psychiatric therapeutic regime.  The defendant appeared disposed to co-operate and unlikely to abscond or behave aggressively. 

Failing a more appropriate forensic psychiatric placement, the neuropsychiatrist who had diagnosed brain damage agreed, at the 11th hour, to admit this young man for further assessment, whilst making clear that his own Epilepsy Unit was not suitable for long-term treatment and rehabilitation. 

The court accepted medical recommendations from the defence psychiatrists and made an interim hospital order under s 33 of the Mental Health Act (1983).  He remained in the Epilepsy Unit for some six months, most of them in an open ward.  An alcohol provocation test showed that moderate levels produced significantly more abnormal brain function, with disinhibition when intoxicated.  He appreciated the implications of these findings, complied impeccably in the unit and matured considerably. 

Visiting his father's grave helped him to start the grieving process and develop appropriate remorse.  He participated well in occupational therapy programmes and developed positive relationships with black and white patients and staff, overcoming underlying difficulties in self-identification which had made him try to deny his mixed origins and associate with "anti-blacks". 

The staff became unhappy at the prospect of their patient returning to prison.  Renewed efforts were made to find a suitable long-term placement to continue his rehabilitation.  Now 18, he had become just too old to qualify for an adolescent unit.  A forensic psychiatrist from an outlying area of the Region, known to have a particular interest in treating non-psychotic offender patients, felt himself precluded from assisting without a referral from his colleague with the designated local responsibility, despite having a vacancy in his unit. 

A black assistant nurse, who had played a crucial part in helping the patient with his problems of racial identity, intercepted that consultant when he happened to be visiting the epilepsy ward insisting that he see the youth, notwithstanding his explaining his catchment area limitations.  An informal interview with the patient and perusal of the papers convinced him that this was a case that warranted help, and also that the previous home address (where he had lived alone with his deceased father) seemed no longer relevant.  A brother lived in the same county as the consultant's forensic unit, so the consultant gladly allowed his arm to be "twisted" and offered assessment facilities for the final weeks of remand.  In the nick of time he was enabled to spend the last three weeks of the maximum permissible six months subject to an interim hospital order in a specialist forensic unit. 

He co-operated fully in many sessions with members of the multidisciplinary team.  Problem areas identified included depression linked to guilt and grieving; severe spider phobia with a possible hallucinatory element; alcohol and drug abuse thought to have originated to alleviate feelings of unhappiness; shyness related to his bodily development, having had a black father, causing inability to achieve relationships with girls.  The forensic psychiatrist concluded that he could be greatly helped by in-patient treatment. 

At the Central Criminal Court in London three concurring psychiatric reports were presented, including a careful analysis of the risk of future dangerousness.  The Judge noted a remarkable change during the six months of hospital treatment and said that he shared the view of the doctors concerned, that the interim hospital treatment power had provided a valuable opportunity to get to the bottom of the defendant's problems.  He was placed under probation for three years, with a condition of residential treatment at the forensic unit, the judge reserving to himself consideration of any application that the patient should live outside hospital before expiry of the probation order.  He did well in the unit, was grateful to all concerned, and in due course he was discharged and eventually became lost to follow-up.  No adverse reports reached the probation service or two of the psychiatrists involved, from whom information had been sought.

Evaluation of the outcome of this murder charge will vary with the individual perspectives of the many professional participants.  The work entailed went far beyond what is normally possible.  Comparable investigations, including the spectacular alcohol provocation tests, would never have been undertaken in prison and would not have been possible without the remand to hospital provisions, which were not yet being widely used. 

An ultimate hospital disposal could not have been achieved without a dedicated medico-legal team approach, and the combination of uncommon persistence with chance.  The solicitor never flagged in his efforts to mobilise support and achieve comprehensive diagnosis and appropriate treatment.  Many obstacles were encountered and calculated risks were taken in deciding to proceed. 

The writer's assistance in negotiations with psychiatric facilities entailed voluminous correspondence, discussions and personal participation in three case conferences, in all of which negative and sceptical views concerning the presence of treatable psychiatric disorder were expressed strongly.  Prospects for any alternative to imprisonment repeatedly came close to foundering against administrative arrangements.  The local health authority was committed to minimising costs and relied for advice upon a psychiatrist whose unit catered chiefly for psychotic offender patients. 

Notional freedom of choice under the National Health Service since its inception had never been formally rescinded, but catchment area boundaries were increasingly paramount in allocating resources, even though specialist units develop differently according to individual professional interests.  Issues of treatability in cases of brain damage and personality disorders offer a fruitful field for clinical disagreements and readily justify decisions to withhold services. 

This patient finally reached his haven because of a series of chance events.  Building works caused the Epilepsy Unit to be temporarily locked, so that the neuropsychiatrist was unusually able to offer the court secure conditions for the initial assessment.  Good co-operation gave enough confidence to allow treatment to proceed in an open ward.  A chance encounter with an importunate nurse at the Epilepsy Unit led to a meeting between the patient and the forensic psychiatrist who had a special interest in personality disorders, with the emergence of a tenuous family residential qualification which provided a basis for admission to his unit. 

By the date fixed for sentencing the patient, by then 19, had adapted well to the move and showed every prospect of benefiting from the unit's therapeutic regime as a base for rehabilitation.  He had previously behaved impeccably for several months in an open unit, so a probation order no longer appeared unrealistic to his barristers. 

This case illustrates demonstrates the importance of flexibility in making available a range of therapeutic facilities untrammelled by administrative obstacles.  There are doubtless numerous comparable prisoners, serving long custodial sentences for serious offences, who might qualify for alternatives to imprisonment if resources permitted thorough investigation to become the rule rather than the exception. 

Note: Efforts to obtain more recent information about the later progress of these defendants have proved unavailing.  One hopes they all settled into normal life. 

PGW, London, November 2000