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SSRI Stories Summary: In July, 1994, a GP prescribes antidepressants to a man, RL, worried when his job disappears as the result of a dockyard closing. They make him impotent and he is consequently unhappy. His GP refers him to mental health services because he is having “relationship problems associated with impotence”. From 1997 to 2002, RL goes off and on antidepressants, and continues to complain of depression and impotence throughout. In April 2001, the NHS doctor prescribes Viagra for RL to help with his continuing sexual dysfunction.
In 2002, there is an incident of drinking followed by mania and strange behaviour. His family complains that he is not taking his medication. Now, he is a man in possible antidepressant withdrawal, on Viagra, and drinking. Now diagnosed with manic depression, there are a number of incidents of inappropriate sexual behaviour, including raping a man. He becomes suicidal. In December he rapes and murders Joan Smythe, an elderly neighbour.
The Independent review is critical of RL’s “non-compliance” with his prescribed antidepressant, despite the fact that it never helped, and addresses the decision to add Viagra rather than help RL get off the antidepressant, as follows: “Viagra would not ‘cause’ sexual disinhibition and whilst it was prescribed, there was no clear evidence to suggest that in RL’s case it was used either to facilitate offending or contributed to inappropriate behaviour.”
KILLER Richard Loudwell is facing sentence after admitting he was responsible for the death of an elderly woman.
He was due to stand trial on a murder charge but his guilty plea to manslaughter by reason of diminished responsibility was accepted by the Crown.
His victim, 82-year-old Joan Smyth, was found strangled at her flat in Wakely Road, Rainham, on December 2 2002. She had bite and burn marks to her body.
John Hillen, prosecuting, told Maidstone Crown Court that acceptance of the manslaughter plea had been a possibility from the outset.
There had been many psychiatric investigations, he said, and Loudwell, 58, of York Farm, Lower Twydall Lane, Gillingham, had undergone a three-month assessment at Broadmoor Hospital.
“It was not contested by the Crown that the defendant was suffering from an abnormality of the mind,” said Mr Hillen.
“The issue was whether, given his denial of any criminal act at all against Mrs Smyth, there was substantial impairment at the time of the killing.”
The prosecution, he said, would not be able to contest evidence that there was impairment.
Judge Warwick McKinnon said he had to have in mind either an indeterminate sentence or a hospital order without restriction.
Loudwell, who spoke only to enter his plea, was remanded in custody until sentence next Tuesday.
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Medway Primary Care Trust & Medway Council Independent Inquiry into the Care and Treatment of Richard Loudwell
On 2 December 2002 Richard Loudwell (RL) killed Joan Smythe. On 22 April 2004 at the Crown Court at Maidstone he pleaded guilty to manslaughter on the grounds of diminished responsibility. The court ordered that he be made subject to an interim hospital order under section 38 Mental Health Act 1983. RL was then detained in Broadmoor Hospital where he was assaulted on 25 April 2004 by Peter Bryan, another patient. This inquiry considers only events to the date of the death of Joan Smythe.
SUMMARY OF EVENTS
3.1 RL was born on the 10 August 1944. He lived in the same farmhouse in Kent all his life, as a child with his parents and two sisters and, after the death of his father in May 1999, solely with his mother. On leaving school, he undertook an apprenticeship and continued to work in Chatham Dockyard until he was made redundant when it closed in 1986. He subsequently found work at GEC Avionics in Rochester, but was again made redundant a few years later. Thereafter he tried several times to find work, including with a kitchen-fitting company, but with no real consistency.
3.2 In July 1994, the GP records indicate that RL was depressed and anxious and he was consequently prescribed an anti-depressant. In August his GP made the first of several referrals to the mental health services, when he was (according to the GP records) seen by a CPN, although no notes of the meeting(s) have been found. Later that year, in November, RL was referred to the psychology department at All Saints Hospital, Chatham for treatment of erectile dysfunction. He was again referred to mental health services in January 1995, when he was once more treated with anti-depressants and during that year continued to see a psychologist regarding relationship problems associated with impotence.
By January 1997, after a minor car accident, RL was again treated for depression. He took to his bed for at least four weeks. At this time he was experiencing extreme financial difficulties because he had unwisely loaned a lot of money to a ‘friend’. Following a further emergency assessment, RL was informally admitted, for the first time, to the Medway Hospital, from 712 March, where he was treated for a ‘brief depressive episode’. During a ward round, his sister reported that he had a tendency whilst at home to stand naked at the door. She also highlighted the possible deepening of his financial difficulties. He was discharged to outpatients with anti-depressant medication.
During April, RL’s sister drew to the attention of the mental health services his inappropriate sexual advances towards women. Throughout the rest of 1997, he continued to be seen at outpatients, complained of continuing depression and impotence and spent an undue amount of time in bed. By December he had ceased taking his antidepressant medication.
3.17 In April  RL was reported as responding well to the Viagra which had been prescribed for his erectile dysfunction. Police received information at this time, from a child care social worker, that RL was planning to move in with his girlfriend, a woman with young children. In a joint police/social services visit to the woman, she disclosed that they had met through a lonely hearts column and that she had no intention of allowing him to move in, or indeed of seeing him again. Police subsequently had reports that RL was frequently at another woman’s home, having been reported by members of the public for parking his car dangerously on the pavement.
3.18 In June … RL’s mother and sister expressed concerns about RL’s strange behaviour, stating that he had exposed himself to an electrician working at the family home. They also drew attention to his extremely arrogant and argumentative demeanour, and the fact that he was dressing strangely. Subsequently, the police and probation officer decided that they should raise RL’s risk assessment from medium to high, as he had admitted exposing himself and there were further complaints from members of the public about his behaviour while working as a kitchen sales adviser. Although at RL’s outpatient appointment in July Dr Shobha could find no clinical evidence of depression, by October, Dr Bhasme once more referred him to mental health services, requesting an urgent assessment and community support, as his condition had apparently deteriorated.
3.20 By January 2002… RL was considered at ‘high risk’ until after his supervision ended in February, because of his behaviour and attitude. At this point, Dr Shobha considered that his depression was in remission and at around that time the GP noted that RL appeared euphoric. In late February there are numerous records of police involvement; at one point he was found wandering in Folkestone claiming he had lost his car or that it had been stolen, was apparently mistaken for an illegal immigrant and kept in the cells overnight. On another occasion RL had asked directions of a stranger, with his trousers around his ankles and pornographic magazines were seen in his car. Three days later he was involved in a road accident and the other party considered that RL was drunk; police found him to be vague and confused and took him to hospital, but he was discharged the same night. The GP, being informed of concerns by the family, requested a further urgent psychiatric review.
3.21 Dr Shobha saw RL on 27 February , accompanied by his sister, who reiterated her concerns that he had been acting strangely for about six weeks, had been aggressive and wandering around naked. He was admitted informally to hospital on 6 March, from the outpatient clinic. He was reported as acting inappropriately to female patients and persisted with this behaviour, despite being requested to stop and being threatened with assault by other patients. RL was discharged on 12 March, apparently because of his sexually inappropriate behaviour, which he had been unable or unwilling to control.
3.22 On 13 May, in a letter to Dr Shobha, the GP requested an early out-patient appointment and CPN visit, after the family raised concerns about RL neglecting himself, ceasing to take his medication and hoarding it. He was consequently admitted informally to hospital once more on 24 May. He was discharged after three days.
3.24 In early October 2002 police received a report that RL was sitting in a petrol station with a pornographic magazine, with his trousers open and his penis exposed. Dr Ratnaike (locum associate specialist) reported that RL had presenile dementia and a referral was made to a psychologist, and his diagnosis changed accordingly.
In late November police received worrying reports about RL; a pharmacy sales assistant reported RL had called into the shop, naked from the waist up, discussing intimate sexual details and requesting to take her photograph; RL was found with an 11-year-old girl, who was returned to her home in Margate. On 30 November, RL was arrested for the assault and rape of a man in Canterbury and was taken to Canterbury Police Station, where he was seen by the custody nurse. RL described himself as ‘manic depressive and bi-sexual’, indicated that he had been in hospital for depression and stated that he had ‘no control over his sexual urges’.
3.26 At 8.00am on 2 December, Mrs D, RL’s sister, tried to phone her mother as she was concerned about the impact on Mrs Loudwell of RL’s increasingly bizarre and troubled behaviour. She then telephoned Colin Croft to register her concerns and to seek assistance. Mrs D received no reply and left a message on his mobile phone. She then visited the farm and found her brother to be emotional and suicidal. An argument developed, culminating in RL threatening to take his own life. At 9.45 the same morning, Mr D, RL’s brother-in-law, telephoned and spoke to RL and asked him to remain at home. Mr D described RL’s behaviour as almost childlike, manic and threatening.
3.27 Evidently RL decided not to remain at home and instead drove to Rainham. Here he met an elderly woman, who coincidentally lived in the same property as an aunt of his (although in a separate flat). He apparently assisted her home with her shopping and was invited indoors. RL sexually assaulted and killed Joan Smythe in her home later that day. He was subsequently convicted of her homicide and was undergoing assessment in Broadmoor when he was assaulted by another patient and later died from his injuries.
Throughout RL’s contact with psychiatric services there are frequent references noting his concerns about potency. There is recognition that this may have affected his mood and compromised compliance with antidepressant medication, on which he occasionally blamed his impotence. Given that his diagnosis was, until his March 2002 admission, one of a recurrent depressive disorder, the need to ensure compliance with antidepressant drugs and the lack of historical evidence of association between his erectile competence and his known offending at that stage, it seems reasonable to have prescribed Viagra.
8.10 RL was first seen by Dr Raleraskar, on 20 May 1998 after a telephone referral from the Christina Rosetti Day Hospital and one failed appointment. He reported erectile difficulties of three months duration that he blamed on the anti-depressant medication. He also expressed concern that his penis and testes were small. Dr Raleraskar suggested the GP refer him to a urologist for a physical examination. The second appointment took place on 22 July 1998 when RL reported being off medication and felt his mood had lifted recently. Dr Raleraskar had no further involvement with RL in her psycho-sexual clinic.
8.11 Hypertension, diabetes, anti-depressant medication, anti-psychotic drugs, depression and dementia can all cause loss of libido or impotence. Viagra is purely a treatment for erectile impotence. It is unlikely that there was a clinically significant interaction between Viagra and any anti-depressants or anti-psychotics RL was receiving.
- The interest in treating RL’s impotence, which was a significant concern to him and something he complained about frequently, may have contributed to his non-compliance with anti-depressant medication.
- Viagra would not ‘cause’ sexual disinhibition and whilst it was prescribed, there was no clear evidence to suggest that in RL’s case it was used either to facilitate offending or contributed to inappropriate behaviour.
8.13 A formal risk assessment in March 2002 would have involved a comprehensive review of RL’s sexual problems, the circumstances in which the problems occurred and details of RL’s sexual activities. A decision to prescribe would then have been premised on the fact that the need to ensure compliance with anti-depressants outweighed the (at this stage theoretical) risk to others. With hindsight, if all the facts had been known, we think it unlikely he would have been prescribed Viagra.
8.14 Similarly, if the unfolding events in December 2002 had been known, then Viagra should no longer have been prescribed. It was only after the alleged rape of AB that the evidence suggested the possibility of penetrative sexual offending. This information, however, was not available either to mental health services or to Dr Bhasme at the time. It should also be stressed that Viagra does not cause sex offending, nor does the prescription of the drug. We also note that there are ways to obtain Viagra without prescription.