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SSRIstories Summary: MC, a socially withdrawn adolescent boy, without family support for school attendance, is referred to NHS Mental Health Services. Before he turns 17 he is prescribed Prozac. He becomes withdrawn, angry, suffers hallucinations, is paranoid, develops agoraphobia and has thoughts of self-harm and suicide. Nobody connects the onset of these symptoms with Prozac. Until he is 24, he is prescribed various psychoactive medications, mostly “anti-psychotics”, to deal with the Prozac side effects, and he often fails to take them as directed. He uses cannabis and drinks heavily. The mental health team blames his paranoia, lack of motivation and other problems on schizoaffective disorder, the cannabis, and drinking. When he complains that he feels worse and becomes aggressive, he is told to keep taking his meds. At 26 he attempts suicide in April by overdosing on a cocktail of illegal and prescription meds, including paroxetine, which has been added somewhere along the way. In July the same year he is arrested on suspicion of murder. A forensic psychiatrist decides that because his symptoms persist when he is not drinking and taking illegal drugs, he has schizophrenia. MC has never been observed while not under the influence of psychoactive medication. The forensic psychiatrist, who first meets MC after the murder, decides that he is not insane in a legal sense.
Last Updated: Wednesday, 10 December, 2003, 15:46 GMT
A man who killed and dismembered the bodies of two prostitutes in Liverpool has been detained indefinitely at Ashworth Hospital under the Mental Health Act.
Mark Corner, 26, pleaded guilty to the manslaughter of Hanane Parry and Pauline Stephen on the grounds of diminished responsibility at Liverpool Crown Court in October. He denied murder.
Body parts of Miss Parry, from Chester, and Miss Stephen, of Skelmersdale, Lancashire, were found dumped in bin bags in an alleyway in the Everton area of the city earlier this year.
At the hearing, the prosecution accepted psychiatrists’ reports he was suffering from paranoid schizophrenia at the time.
Corner had been known to psychiatric authorities since he was 17-years-old, and was a community patient of Merseycare NHS Trust.
The trust says it is reviewing the way it cared for him.
In a statement it said: “Providing care in the community for patients with mental health problems is not an exact science, and ensuring service users take medication regularly and attend for appointments can be problematic.”
The dismembered bodies of Miss Parry, 19, and Miss Stephen, 25, were found in the red light district of St Domingo Vale on 20 July.
Body parts were later discovered in bin bags at the back entrance to Corner’s flat in Everton, in his freezer, and dumped at Stanley Park, in the shadow of Liverpool FC’s ground.
Police were alerted to Corner’s crimes after he confessed what he had done to his brother Ian.
After he was arrested, psychiatrists concluded he was suffering from “hallucinations, delusions and violent and sadistic thoughts”.
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Independent Review into the care and treatment of Mark Corner Commissioned by Cheshire and Merseyside Strategic Health Authority
Excerpts from actual report:
This section of the report provides a chronological review of the significant events entered within the clinical documentation reviewed in relation to the care and treatment of MC…
4.3 November 1990. Aged 13 years, MC was referred to Mental Health Services due to a possible depression. He was seen on four occasions and also interviewed by an Education Welfare Officer due to his failure to attend school.
[In 4.8, we learn that at some point MC has been prescribed Prozac, but the initial prescription is obviously not deemed a significant event by the investigators. It would explain certain things, however, like the self-harm and the suicidal thoughts – SSRI Ed]
4.5 June 1993. MC was referred for counselling by a community paediatrician. He had difficulties attending school and was deemed to be suffering from low esteem and an inability to mix in addition to a tendency towards violence. Since his admission to special school staff felt there was a pent up anger and this was causing some concern.
4.6 October 1994. Aged 17. MC was seen by his GP and complained of depression, hearing whispers and of thoughts of self-harm. He was referred for further assessment in a week’s time. During the second assessment it was noted the symptoms remained and he was referred for a mental health assessment.
4.7 November 1994. MC was seen by a Consultant Psychiatrist at home following a referral by his General Practitioner. He was assessed as being fairly inactive and had not left the house for the previous two months due to the fact that he felt that people were looking at him. On examination he was assessed as depressed. He expressed thoughts of suicide and there was no evidence of thought disorders or hallucinations. The psychiatrist opinion was that MC was suffering from agoraphobia consequence upon long standing depression and social difficulties. The long term plan considered for him was attendance at the Oakdale Unit for help with his agoraphobia.
4.8 February 1995. MC as admitted under the care of the mental health team at Fazakerley Hospital, via the accident and emergency department. He presented as feeling low with a disturbed sleep, aggression and irritability. He reported paranoid thoughts regarding people being in the house at night and claimed to hear voices of people talking in the house. He indicated that he had not been taking his prescribed Prozac medication. A care plan was completed. MC was reported be suffering from regular mood swings and suicidal ideation. The short term goal established was to stabilise his mood in order to reduce the onset of aggression and thoughts of self harm with the long term goal to establish a network of support to improve MCs coping skills.
4.9 March 1995. MC was discharged from Fazakerley Hospital with a working diagnosis of a depressive illness. He had made some improvement on the ward but remained very low. He was given an appointment to attend the Oakdale Unit and prescribed Dothiepin 75mg nocte. MC attended the Oakdale Unit later that month and his medication was changed to Thioridazine 50mg nocte and Dothiepin 75mg nocte. No evidence of harm to himself or others was observed or of neglect and there no risk was identified.
4.11 July 1995. MC was admitted to the observation ward in accident and emergency following an overdose of Dothiepin. He admitted this was due to strange thoughts and reported homicidal ideas during this time. He appeared withdrawn with no auditory hallucinations and no clear defined symptoms of depression. A psychiatric review whilst on the ward elicited hatred towards other people and a sense of frustration. MC indicated his hatred was great enough to harm others. The clinical impression was one of possible incipient schizophrenia or schizoid personality disorder.
4.13 September 1995. Following a GP attendance it was noted MC still felt depressed and indicated a non-compliance with prescribed medication. No thoughts of self harm were noted but motivation appeared poor with limited eye contact during this attendance. MC indicated he was willing to try a different antidepressant and was prescribed Lofepramine 70mg.
4.16 April 1996. Aged 19 years, he was re-referred to mental health services by his general practice.
A further visit that month to his GP indicated he was drinking heavily but refused a referral to the Windsor Clinic for assessment for this problem. He was prescribed Chlordiazepoxide 10mg for one month.
4.21 January 1999. Aged 21 years: GP review visit. MC is currently prescribed Paroxetine. He indicates that this drug helps his anxiety but not his depression and complains of erratic sleep patterns.
4.22 February 2002. MC is seen by his GP and observed to be in employment as a security worker. He reports it’s a stressful job due to the need to interact with people. He reports a disturbed sleep and appetite with subsequent weight loss. Increasing levels of aggression are reported since ceasing Paroxetine which he had stopped taking. It was suggested that he recommenced this and was given a further prescription.
4.23 May 2002. MC reported to his general practitioner on a follow up visit that he had stopped taking Paroxetine as he felt it was not helping. He reported his symptoms to be worsening with increasing aggression. He was asked to re-attend at a later date.
August 2002 It was noted during a GP visit on 6th August that MC had been smoking cannabis and had increasing paranoid thoughts and hearing voices through the walls.
On 18th August 2002 MC was admitted to the Ferndale Unit, Merseycare NHS Trust via the accident and emergency department. MC had indicated he could hear the neighbours talking about him through the walls of his property and he was taken into police custody after an apparent attempt to remove a kitchen knife and move towards the neighbours’ house. On admission with a Police escort he was not able to speak and could not be assessed for purgative function. He was prescribed Lorazepam 4mg.
Subsequent clinical consultations revealed a long standing history of cannabis misuse and concurrent cocaine and heavy alcohol consumption. He reported the fact that he was a body builder and was on regular steroids but self admitted to administration of more than the recommended doses. He further reported auditory hallucinations and discussed the ideas that his neighbours were talking about him and thought that cameras were spying on him. He had been suffering from poor sleep, had lost significant weight and further had been terminated from his employment.
He was detained under Section 2 of the Mental Health Act (1983) under the care of a Consultant Psychiatrist.
During this admission a risk assessment was conducted which indicated the following:
- Suicide = 48 (moderate/severe) • Violent aggression = 53 (moderate/severe) • Neglect = 1 (low)
4.25 19th August 2002. It was noted that during this admission MC had been hostile towards members of staff and reported the fact that neighbours had been speaking about him. He had admitted that he may have used the knife. He reported that his family couldn’t hear the voices but he clearly can. MC was given a diagnosis of schizophrenia and started on an antipsychotic medication: Olanzepine.
4.26 23rd August 2002. It is reported that MC was much more settled on the ward although quiet and subdued. No thoughts of harm to himself or others were expressed. During this time it was noted, from a previous set of clinical notes, that MC had had thoughts of harm towards others and a morbid fascination with people who had died after they were mutilated. However, it was recorded that during this assessment MC had not indicated thoughts of this nature. MC was reported not to engage with a new risk assessment although there were no obvious signs of hostility or threats of violence since his admission. He was re-graded to level 2 (intermittent) observations with a long term goal of discharge from the unit with relevant community after care.
4.27 27th August 2002. MC’s Consultant Psychiatrist presented a report to the Mental Health Review Tribunal. He was of the opinion that MC was suffering from a psychotic illness which required further assessment and treatment. He acknowledged that the incident leading to MC’s admission was a very serious one and that there will be a risk to himself and other people if he were to be discharged prematurely.
4.28 28th August 2002. The Mental Health Review Tribunal’s decision was that MC was not to be discharged. This decision records no discharge “in the interests of his own mental health and the protection of others”. It was deemed MC was suffering from schizophrenia with a continuing evidence of psychosis and a lack of insight into his condition. He was thought not stable enough for discharge.
Following the decision MC was subdued but settled with no obvious abnormal perceptions. He agreed that he should stop cannabis as this clearly added to his paranoia but continued to believe that his neighbours were talking about him but admitted that this feature had become to bother him less. He was allowed to have Section 17 leave for the weekend and one hour of unsupervised leave on the grounds.
4.29 2nd September 2002. His weekend leave was uneventful with no problems reported. He did not experience any problems with his neighbours and began to question whether or not he had actually heard any voices at all. He was granted more weekend leave and six hours leave per day.
4.30 3rd September 2002. A detailed past medical history was taken by a Senior House Officer in Psychiatry. He described a difficult childhood with frequent absences from school with infrequent alcohol consumption, cannabis, with LSD and “downers” taken infrequently. He disclosed that he had been once remanded into custody for a few hours for having a modified powerful airgun.
4.31 10th September 2002. MC returned from leave with no reported problems. He appeared compliant with his medication and denied using cannabis. He indicated he was keen to be discharged.
4.32 11th September 2002. MC was re-graded from Section 2 Mental Health Act (1983) to informal status. He was discharged from hospital with no psychotic phenomena and a good insight into his illness.
In a discharge letter to his General Practitioner, the Senior House Officer reported that his progress on the ward was rapid and that it was thought that his psychotic phenomena could have been induced by cannabis. He had been discharged and prescribed Olanzepine 10mg with a working diagnosis of paranoid schizophrenia. The Senior House Officer assessed his risk as low to himself and others and of neglect low. He indicated that MCs prognosis was good if he remained cannabis free and remained complaint with his medication. He was to be reviewed again in outpatients in three weeks time.
4.33 11th September 2002. A note is made in the Care Programme Approach documentation that indicates a diagnosis of ‘depression’ (of note to the investigative team: CPA documentation including risk assessment and required level of CPA not completed). Relapse markers noted included increased use of cannabis and cocaine abuse and increased levels of paranoia.
Nobody is listed under the persons present at the care meeting review.
Medication prescribed Olanzepine 10 mg nocte.
No date for CPA review was set and an outpatient appointment was fixed for 7th October 2002.
4.34 12th September 2002. MC was referred for a Community Psychiatric Nurse visit by his Consultant Psychiatrist.
Later that month, although the date is not clearly identified, MC was visited by the Community Psychiatric Nurses (CPN’s) following this request. No risk assessment was conducted. The CPN’s reported to be not aware that MC had previously been the subject of detention under Section 2 of the Mental Health Act (1983).
4.35 21st September 2002. MC was seen in the accident and emergency department by a duty psychiatric Senior House Officer. He had taken an overdose of Paracetamol, the aim of which he indicated was to aid his sleep. It is noted that he had been diagnosed the week before with paranoid schizophrenia. He self reported a non-compliance with his prescribed Olanzepine medication and reported heavy alcohol consumption in the previous few days.
He also reported to be feeling isolated and lonely. He was given a four day course of Zopiclone and discharged. A member of his own family phoned shortly afterwards to express concerns that he was not fit to be discharged. He was referred to the Crisis Management Team of Mental Health Services and for review in outpatients.
4.36 23rd September 2002. MC was contacted by the Crisis Management team. He reported feeling much the same and denied any suicidal thoughts and indicated that a prescription was waiting for his anti-psychotic medication at his GP’s surgery.
4.37 24th September 2002. The Crisis Management Team contacted MCs Consultant Psychiatrist. They discussed recent events and MCs family’s concerns regarding the need for Community Psychiatric Nurse visits and an urgent outpatient appointment. It was noted that his consultant would liaise with the CPNs and arrange for an outpatient appointment.
4.38 7th October 2002. MC was assessed by a Senior House Officer in Psychiatry in outpatients. Since his discharge from the Ferndale Unit it was noted he had stopped taking his prescribed Olanzepine and resumed significant consumption of alcohol and cannabis. The paranoid thoughts and auditory hallucinations had returned. It was noted that he had started hearing voices again indicating that the neighbours were talking about him, despite the fact he had moved into a new flat. He mentioned he had threatened a neighbour with a knife who had called the police who gave him a verbal warning. He had moved back home because he was feeling lonely and had restarted his Olanzepine. However, he thought his paranoid thoughts had remained.
He was prescribed Venlafaxine 75mg od. His General Practitioner was requested to prescribe these as required. It was planned to review him in four weeks time. A risk assessment conducted indicated a categorised risk to himself and others as ‘low’ with a ‘moderate’ risk of neglect.
4.39 25th October 2002. MC failed to attend his outpatient appointment.
4.40 7th December 2002. MC was admitted to the accident and emergency department, Aintree Hospital with injuries sustained during an assault. It was noted that he was intoxicated and admitted he was drinking considerably. He was observed for a while on the short stay ward and discharged to the care of his parents.
4.41 13th January 2003. MC failed to attend his scheduled outpatients appointment. The Senior House Officer had noted that the matter should be discussed with the Community Psychiatric Nurses before making a further appointment.
4.42 21st January 2003. MC was seen by his General Practitioner and he was noted to be drinking significantly. He reported he had stopped his prescribed medication three months ago.
4.43 31st March 2003. MC failed to attend a scheduled outpatient appointment. His case was to be discussed.
4.44 18th April 2003. Aged 26 years, MC was admitted to the observation ward via accident and emergency department at Aintree Hospital following an overdose of a mixture of drugs: Largactil, Ecstasy, Paroxetine and Dihydrocodeine. He indicated he had been using 60 to 70 Ecstasy tablets per week for the previous six months. Following some time on the observation ward, he was discharged on the 19th April 2003 to the care of his General Practitioner.
4.45 21st July 2003. MC was arrested by police on suspicion of murder.
4.46 23rd July 2003. MC was arrested again on suspicion of a second murder.
4.47 13th October 2003. MC was assessed by a Consultant Forensic Psychiatrist. He expressed the following opinions:
MC was not under disability with respect to court proceedings.
MC did not satisfy the criteria for “insanity” as he clearly recognised that his actions were wrong.
MC described symptoms suggesting an underlying psychotic illness. Such symptoms were consistent with the diagnosis of schizophrenia.
There was also evidence of early conduct disorder. He had met the criteria for both paranoid and schizoid personality disorders.
MC gave a history of alcohol and illicit substance abuse. The symptoms of his mental illness persisted in the absence of drugs and alcohol thus indicating that his psychotic symptoms were a product of an underlying mental illness rather than as a result of intoxication.
MC suffered from an abnormality of mind caused by the presence of both mental illness and psychopathic disorder.