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SSRI Stories Summary: David Clairmonte is prescribed sertraline by his GP for Crohn’s in 2009. He becomes suicidal, threatens to jump off cliff, gets into serious debt, takes illegal drugs, breaks up with girlfriend, GP sends him to Luton & South Bedfordshire CRHTT. “Non-compliant with medication” he quits taking sertraline in late May, 2011. He becomes agitated, disturbed, June 17 he burgles his father’s home, entering by breaking a window. “A few days later”, he bludgeons 69-yr-old neighbour Fred Hodson to death during an attempt to get his PIN and steal from him. He is arrested and charged June 25, 2011. The independent review does not explore the potential role of the medication in the violence, and the news article does not even mention it.
7 March 2012
David Clairmonte tried to obtain a loan in the hours before the murder
A man burgled his father’s home days before he bludgeoned a widower to death, a court has heard.
David Clairmonte, 26, of Thornview Road, Houghton Regis, was jailed for life in January for the murder of Fred Hodson in Luton.
At Luton Crown Court earlier, he admitted to two burglaries, on 11 and 13 June, days before killing Mr Hodson.
Clairmonte was jailed for two years, to run concurrently with his 30-year term for Mr Hodson’s murder.
Daniel Siong, prosecuting, said Clairmonte broke into his father’s home in Statham Close, Luton, by smashing a conservatory window.
He took a 42in television, and two days later went back and in total took £10,000 worth of items.
His father was on holiday at the time.
In January, a jury heard Clairmonte attacked Mr Hodsdon for his Personal Identification Number, because he was desperate for cash.
He bound the 69-year-old’s hands with electrical tape and led him from room to room, beating him 13 times around the face and head with a hammer he had found in the garden shed.
Clairmonte had denied murdering Mr Hodson, claiming he had stumbled on the “horrific” aftermath at the house in Vespers Close, Luton.
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Niche – An independent investigation into the care and treatment of a mental health service user (Y) in Bedfordshire by South Essex Partnership University NHS Foundation Trust
1.5 On the early evening of 25 June 2011 Y went to the house of Mr Z in Luton. He had met Mr Z previously, when Y had worked on his roof with his father. Y attacked Mr Z with a hammer, allegedly to try to gain the PIN for his cash card. Mr Z was discovered by a neighbour and died in hospital later that evening from his injuries.
1.6 Y had two short periods of contact for assessment with secondary mental health services in April and June 2011.
1.7 He was initially referred to mental health services by his GP on 19 April 2011, after being found by police threatening to jump off a cliff. He was seen for assessment on 24 April 2011 by the Luton & South Bedfordshire Crisis Resolution and Home Treatment Team (CRHTT) and was assessed as not suicidal or a risk to others at the time. He refused to be referred to the community mental health team (CMHT) and was referred back to his GP.
1.8 On 23 June 2011 his GP again referred him to the CRHTT after he had attended Accident and Emergency at Luton and Dunstable Hospital (A&E) having cut his wrists, and presented to his GP with depression and suicidal ideation.
1.9 Y was assessed on 25 June 2011 by a nurse and healthcare worker from the CRHTT, and was offered admission to the short term mental health assessment unit (MHAU). The assessment noted that Y reported he had split from his girlfriend two weeks previously, that he had debts of up to £10,000, and was unable to work because of his physical illness (Crohn’s disease1). It was also noted that he said he was on police bail for criminal damage to his girlfriend’s home, due to return to the police on 28 June 2011. He was offered admission to the MHAU with agitation, restlessness, low mood and fleeting suicidal thoughts; for ‘further assessment of his mental health state’. The assessment notes record ‘if declined, to be offer [sic] home treatment’. The plan following the assessment was not agreed and documented.
1.10 The CRHTT received a phone call from Y’s aunt later on 25 June 2011 stating that she had spoken to Y and he was refusing to come into hospital and was not at home. It was planned to visit Y the following day, and a telephone call was made to him by the CRHTT. There was no voicemail facility. At 10.20 on 26 June 2011 a phone call was made by the CRHTT to Y; he did not answer and there was no voicemail facility. The team then phoned his aunt who told them Y had been picked up by the police the previous night because he was disturbed at home. The family had called the police after Y threatened to harm himself whilst under the influence of alcohol.
1.11 Later that evening [June 25, 2011] Y was arrested on suspicion of the murder of Mr Z.
1.12 A Mental Health Act assessment was carried out in custody and he was judged to be fit to be detained and interviewed.
1.13 On 26 January 2012 Y was found guilty of murder, and sentenced to life imprisonment, with a recommendation that he serve 30 years. It was acknowledged in court that Y’s brief contact with mental health services played no part whatsoever in the incident. Y entered a plea of not guilty of murder and there was no plea in relation to manslaughter due to diminished responsibility…
4.7 Psychiatric history
4.7.1 Y’s stepfather left the family home in December 1995, when Y was 10. His mother reported that Y had become withdrawn and would not speak to anyone in the family. His mother asked the GP to refer him for counselling. The GP wrote to Child and Family Services in February 1996, but there is no record of any follow up. Y’s family reported that he wasn’t ever seen by Child and Family Services.
4.7.2 A GP referral was made to the Community Mental Health Team at Beacon House, Dunstable, following a consultation on 19 April 2011. Y attended his GP’s after being found by police attempting to jump off a cliff 2 days previously, and the police had instructed him to see a doctor.
4.7.3 Y reported making a suicide attempt in the past, but had not apparently discussed this with his GP.
4.7.4 He was seen at his home address by the Crisis Resolution and Home Treatment team (CRHTT) on 24 April 2011, and told them this crisis was mainly triggered by splitting up with his girlfriend, and that he also was unemployed and had financial difficulties. He said he had been drinking at the time, and wanted the police to shoot him because he didn’t have the courage to kill himself.
4.7.5 Y was offered a referral to the Community Mental Health Team (CMHT) psychiatrist but he declined, saying he didn’t want to be locked up, and was not mentally ill. He was advised to seek help for the anger problems he described, but refused, reportedly saying he didn’t need any counselling or therapy. He said he would rather be treated by his GP, and the assessment report back to the GP suggested medication to help with sleep and fluctuating moods.
4.7.6 He was again referred to the CRHTT on 23 June 2011 after seeing his GP in the company of his aunt. Y had cut his wrists 2 days earlier and attended A&E for treatment. This GP had just taken Y on as a patient since his previous GP retired, and had met had only met Y once before, some years previously. The GP reported that Y had been prescribed Sertraline8 50mg, and had been feeling better, but had stopped taking it about 4 weeks previously.
4.7.7 He was described by the GP as being suicidal and low in mood, but difficult to engage. The GP phoned the CRHTT to arrange an urgent appointment. The GP reported to the internal investigation that the CRHTT agreed to offer an assessment within four hours, and he recorded in the GP notes that it was his understanding that Y and his aunt would be together until this assessment occurred.
4.7.8 Y was contacted by the CRHTT on 23 June 2011. Notes record that he said he didn’t want to see them at home on the initial date and time offered because he wanted his aunt to be present, and she was not available until 25 June. An appointment was arranged for 25 June 2011. He was seen at the CRHTT office in Lime Trees, Luton with his aunt on 25 June 2011
4.7.9 Y was seen and assessed by a qualified nurse and a healthcare worker, accompanied by his aunt. The assessment recorded that he had suicidal thoughts, had split up with his girlfriend and had debts up to £10,000. Y reported that he had no money and had resorted to selling his property to live. The assessment reported him as being ‘non-compliant with medication’. He described poor sleep due to his Crohn’s disease symptoms, and was taking painkillers (diclofenac9) for pain. At this time Y had been prescribed sertraline 50mg and diazepam10 4mg. 4.7.10 The assessment took place with Y’s aunt present, though staff also spoke to each of them independently.
4.7.11 Y told these staff that he had no history of contact with mental health services, and it was reported in the assessment notes that this was his first referral. This was not in fact true, as he had been assessed by the CRHTT in April 2011 after a similar GP referral. This assessment was referred to in the GPs faxed referral letter of 23 June 2011.
4.7.12 Y was noted to be restless, anxious and ‘very disturbed’, with low mood. Risk to self was recorded as 2 ‘medium’ on the Trust’s ‘First contact/crisis assessment of risk’ form. This form also recorded his risk to others as 1 ‘low’.
The recorded plan was to offer admission to the MHAU for ’further assessment and monitoring of his mental health’. A bed was booked at MHAU, and it was recorded that he should be offered home treatment if he declined. We interviewed the assessing nurse, who reported concern that Y did not know what medication he had been prescribed, or where his tablets were. The result of this assessment was a recommendation that he should be admitted voluntarily to the MHAU, where he could be helped with his agitation…
4.4 Substance misuse history
4.4.1 Y disclosed to CRHTT staff that he had used cannabis in the past, but it didn’t agree with him, and he was drinking 10-15 units of alcohol per day in June 2011, which was more than he usually drank. The assessment reports that Y said he had taken cocaine in the past, most recently about two months previously.
4.4.3 In a statement to the police his ex-girlfriend has claimed that both she and Y were drug users, using speed, cocaine and crack and Y had begun to steal to fund his drug use.
|Not noted in report||Date would be some time between 2009 when ”Y” went to his GP and was prescribed medication for Crohn’s, and April 19, 2011, when the GP referred him to CMHT, Beacon House, for threatening suicide||Prescription issued for sertraline (Lustral, Zoloft)
By June 23, 2011, the report noted that he had been taking sertraline but stopped 4 weeks previously, one month before the murder
|16 or17/4/11||GP notes||Caught by police trying to jump off a cliff- was advised to see GP, saw GP 19/4/2011 and talked of suicide|
|19/4/11||GP notes||Referred to psychiatry, beacon house, Dunstable asking for assessment|
|24/4/11 GP notes||Seen by CRHT team at home. Refused CMHT input, not suicidal at interview, advised to see GP for medication if needed.|
|23/6/11||SEPT notes||GP letter asking for Y to be seen again (mentions April assessment) was taking Sertraline but stopped 4 weeks ago. Cut to wrists & suicidal thoughts.