Key workers lacked experience to deal with killer, inquiry concludes

BMJ 2009; 339 doi: (Published 07 September 2009) Cite this as: BMJ 2009;339:b3648
  1. Clare Dyer
  1. 1BMJ

    A “systemic failure” allowed Peter Bryan, a dangerous, mentally ill killer who went on to kill two more people, to be supervised in the community by an inexperienced psychiatrist and social worker, an independent inquiry has concluded.

    Mr Bryan, who has schizophrenia and has since been given a diagnosis of a personality disorder, killed an acquaintance, Brian Cherry, in 2004 and then fried and ate part of his brain. Ten days after he had been detained in Broadmoor high security hospital for the killing, he attacked a fellow inmate, Richard Loudwell, who later died of his injuries.

    The reports of two separate inquiries into the two incidents, carried out for the strategic health authority NHS London, found a catalogue of failings in Mr Bryan’s care and supervision. But they point out that he was a highly unusual patient who appeared normal even when he was seriously mentally ill.

    The inquiry into the killing of Mr Cherry, chaired by the barrister Jane Mishcon, concluded that no particular failure by any individual professional directly precipitated the outcome.

    But it found “a systemic failure to ensure that the key professionals allocated to care for him in the community had the necessary experience to deal with someone with his forensic history and complex presentation.” The professionals were a general adult psychiatrist who had no experience of supervising a killer and an inexperienced social worker with no training in mental health.

    Mr Bryan had beaten a shop assistant, Nisha Sheth, to death with a hammer 11 years earlier, but apart from a few incidents in the early years of his detention at Rampton secure hospital he had displayed no violent or aggressive behaviour since.

    He had been released from Rampton, spent six months on a locked ward in Homerton Hospital in east London, and had been living for two years at a residential forensic hostel, Riverside House, in north London. At the time he killed Mr Cherry he was a voluntary patient on an acute general adult psychiatric ward, but he was there not because of his behaviour but for his own protection after a teenage girl accused him of indecent assault and her family made threats against him.

    The inquiry report noted that the unnamed psychiatrist who was supervising him, a “caring and conscientious general psychiatrist,” took responsibility for Mr Bryan’s supervision “with great reluctance.” Had Mr Bryan been under the care of a community forensic team, the report said, the subtle signs of his increasing risk of relapse and reoffending might have been picked up.

    But it added that it should not be forgotten that, even in the high secure setting of Broadmoor, he was later able to kill a fellow patient.

    The inquiry into the Broadmoor killing, chaired by Robert Francis QC, condemned the hospital for “a lack of leadership at most levels of management and little common purpose within the hospital to deliver a first class service to patients and the public.”

    Ten days after arriving at Broadmoor Mr Bryan had still not had a risk assessment, and no staff were observing the dining room, where he carried out the attack.

    Peter Cubbon, chief executive of West London Mental Health Trust, which runs Broadmoor, said that closed circuit television had been introduced and preadmission assessment procedures had been revised, and the dining room was now locked unless staffed.

    Robert Dolan, chief executive of East London Foundation NHS Trust, responsible for the community services that supervised Bryan, said, “The trust has established new systems to ensure that patients with a history of violence are under the care of staff with sufficient experience and training to look after them.”


    Cite this as: BMJ 2009;339:b3648

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