In Memoriam: Kenneth Severin, Jimmy Mubenga and Sean Rigg

Postscript to Experiences of a Medical Whistleblower in Great Britain 
 
This postscript documents protracted and abortive searches for truths from 1994 to 2013 and is dedicated to the memory of three of the many men who have died under "restraint" in UK custody; some in the presence of witnesses who heard them plead that they were being killed by officials responsible for their care.

 
In Kenneth Severin's case, with which I was directly involved as the Mental Health Review Tribunal (MHRT) doctor, vital evidence has been withheld and probably destroyed.
 
His death in November 1995 was the subject of a Channel Four TV investigative documentary Citizen's Arrest; Death in Custody, made before my involvement became known. The twists and turns in the saga are documented from my psychiatrist's perspective in several publications.

The issues have continued to concern me ever since Severin's 1994 Hearing at which I was the medical member and had strongly urged his continuing need for compulsory care and treatment in hospital, as confirmed in our MHRT Decision. 

 
Although well known to have been suffering from schizophrenia, as too had his father, the applicant Kenneth Severin was thought to be not mentally ill, but simulating it, by a "care manager" social worker who represented Social Services at the Tribunal hearing, but resented questioning.

Two completely unforeseeable consequences ensued : 
A. the preventable death of that mentally ill patient.
B. the writer's suspension by the Regional Chairman and eventual dismissal from the medical panel of the MHRT.
 
I have continued to pursue my enquiries into his case ever since 1994. Outrage at my suspension was expressed widely, most cogently perhaps by the hospital doctor present throughout the Hearing: 
 
"I recently attended a Mental Health Tribunal regarding Kenneth Severin, as the nominated deputy of his consultant. Given the complex nature of the case I found Dr Woolf's questioning of the Care Manager, the patient and myself, wholly appropriate. Dr Woolf's firm, fair and probing questions were necessary to elucidate the finer aspects of this case".
 
Soon after leaving hospital Mr Severin was homeless and in trouble and was remanded to prison, where he was set upon by prison officers and suffered severe "restraint" leading to his death.

 
The hospital notes are silent as to when he had left hospital, whether he had been formally discharged, allowed leave, or simply had absented himself whilst still "under Section".
 
Nowhere in the medical notes is to be found a consultant's Discharge Report, not even a note to explain what had happened.  Nor is there a copy of the Tribunal's findings - just a cryptic entry signifying the social worker's "surprise" at the outcome of the Tribunal deliberations. How and why Severin was allowed to leave hospital with no notated explanation is central to the tragic consequences. 

 

I was eventually allowed to see a large bundle of photo-copied hospital papers and perused them in vain for a customary Discharge Report.  I had been obliged to search these on my own, because a psychiatric consultant who had been detailed by the Trust's Information Governance Supervisor to invigilate my inspection of the actual hospital notes, finally could not spare time to do so.

Kenneth Severin's family have appreciated my involvement, of which they only learnt long after the Inquest, but numerous attempts to achieve personal meetings and open discussion with representatives of relevant organisations have been resisted and evaded through the years. Those who have declined to meet included the Council on Tribunals; the General Medical Council; the charity Inquest and its lawyer; the Royal College of Psychiatrists; two MHRT Regional Chairs; the local Hospitals Trust, and government ministries such as the Department of Health and the new Justice Ministry.

As a known sufferer from mental illness, Kenneth Severin ought not to have been remanded in prison at all, and certainly not without the prison staff being made aware of his mental condition. Should their ignorance, and my difficulty in pursuing this study, be laid partly to the account of the provisions of the Data Protection Act and unintended effects of confidentiality guidelines, both of which have hampered enquiries?
 
It appears that Severin’s aggressive paranoia had scared neighbours, who got rid of him by setting fire to his flat, and that it caused the prison officers to take extreme measures to control him.  In Court the officers' defence was that Severin was remarkably strong and that his aggression scared them into taking extreme action.
 
At his Inquest, the Coroner criticised comprehensively poor communications between the different agencies, with many aspects of the management of his case contributing to his death in custody.

I received assistance from the Society of Clinical Psychiatrists' Suspensions Support Group, and took an opportunity to bring a press notice of Severin's fatal outcome to the attention of the Regional Chairman, with a paradoxical consequence that doing so annoyed him by showing up his earlier action in 1994.

So, after another MHT Hearing he found a trivial, spurious basis upon which to suspend me again, compounding it by contriving to have me dismissed from the medical panel by the Lord Chancellor with (as it turned out) the latter's Decision carrying no Right of Appeal.

Before all this blew up, that Regional Chairman had previously sought - secretly - to prevent "his" doctors from continuing to act as Expert Witnesses assisting lawyers with independent medical reports; a normal professional activity.
 
Furthermore, Mr Severin's Social Records proved impossible to find.  Eventually the local Council's Information Governance Officer opined that "they might have existed", telling me that the Borough has no system in place to ensure the retention of sensitive material in contentious cases.
 
What became importantly clear was the complete separation of the local Health Authority Trust from the Council, the latter responsible for social records keeping.  I have urged a local psychiatrist representing a Royal College of Psychiatrists project on discharge reports to ensure that social and clinical reports should be combined in the national protocol they are developing.

 
I have been concerned about these issues ever since Mr Severin’s 1994 Hearing. The social worker‘s resentment of essential questioning had two repercussions; the preventable death of her mentally ill client under prison staff "restraint", and my own suspension and subsequent dismissal from medical membership of the MHRT after 30 years service.
 
A full account of these interrelated consequences are dealt with in my extended reports, widely published.
 
This postscript has summarised obstacles encountered in exploring these closely interrelated matters, notably the evasiveness of medical and government departments, and the widespread avoidance of face-to-face discussions.
 
A key factor in my own experience had been the appointment of the above mentioned MHT Regional Chairman, a retired Crown Court Judge, following the tragic premature death of his long serving solicitor predecessor, a wise colleague and friend to his panel colleagues.

His successor effectively brought to abrupt termination my lengthy and varied medico-legal psychiatric career. He avoided disclosing essential correspondence, failed even to to respond to the Lord Chancellor himself, and latterly ignored enquiries from a leading Whistleblower organisation.

A letter of Complaint to the Lord Chancellor rebounded on me, as is the fate of whistleblowers.  Even my own MP, whose several representations on my behalf had never been properly addressed, eventually gave up.
 
The charity INQUEST (http://www.inquest.org.uk/) (http://inquest.gn.apc.org/issues/home) has highlighted the reluctance to approach deaths in custody as potential homicides, even when there had been systemic failings and gross negligence.

A disproportionate number of mentally ill people and those from minority ethnic communities have died as a result of excessive force, restraint or serious medical neglect. None of INQUEST's cases has led to the prosecution of their attackers. Restrictions on admissibility of witness testimony may have contributed to that anomaly.  Not a single one of the alleged perpetrators has been convicted of a criminal offence.