In Memoriam: Kenneth Severin, Jimmy Mubenga and Sean Rigg
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.
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/
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.
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Jimmy Mubenga, an illegal immigrant, died at Heathrow Airport on 12 October 2010 during his forcible removal from England back to Angola, being deported by G4S Security (the commercial firm notorious for the security arrangements fiasco at the Olympics). Another passenger on the plane heard him screaming about the escorts: "They're going to kill me." No one was held responsible for his death.
Sean Rigg, another man suffering from a florid relapse of schizophrenia, died in August 2008 in inappropriate police custody. His death was found by the inquest jury to have followed the use of unnecessary force by the police.
His death in custody, like Severin's, has also been the subject of a searching TV documentary film
[http://vimeo.com/46132509]. Police are not expert in recognising even serious acute mental symptoms. Rigg’s family has pressed for criminal charges against those responsible and for a public inquiry into deaths in custody.
There has not been a single successful homicide prosecution for a death in custody in UK. The questions raised in the Channel 4 film and in my published papers about Severin's case have not yet evinced wider media interest.