Death could have been prevented — (BBC NEWS)

SSRI Ed note: Street drug user has problems, NHS gives psych drugs incl. sertraline. Quits drugs, murders man. Mental illness, supervision blamed. Reoffends 8 yrs later.

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SSRI Stories Summary:  JP has history of abusing amphetamines.  He comes to the NHS in 1993 at the age of 25, complaining of suicidal thoughts and depression.  Instead of helping him get off the speed, the NHS loads him up with neuroleptic medication.  By May, 2001 he is also taking 100 mg sertraline (Zoloft/Straline), an SSRI.  He continues with the SSRI and Olanzapine but stops showing up for his depot shots of other medication.  He continues to use amphetamines. On May 1, 2002 the NHS receives reports from neighbours that Mr Peters is behaving strangely, flashing, setting fires and ranting.  It seems he is becoming delirious/psychotic.  On May 12 Peter murders a neighbour for no reason. He is convicted of manslaughter, pleading diminished responsibility and confined in two psychiatric facilities. He is released back into the community in 2005, and in 2010 he is charged and convicted of trafficking amphetamines.

The stated NHS position is this:  “Although we monitor and maintain our service users in the community, we cannot be responsible for criminal behaviour that is not linked to an individual’s mental health.”   Had the amphetamine addiction been addressed instead of giving Mr Peters additional psychoactive drugs, the murder of Mr Warnes might never have happened.

BBC NEWS | UK | England | Devon

Thursday, 15 July, 2004, 13:26 GMT 14:26 UK

The killing of a Plymouth postal worker by a psychiatric patient may have been prevented if health workers had done more to help him, an inquiry has found.

The independent inquiry was looking into how John Peters killed 60-year-old Roy Warnes in May 2002.

John Peters has since been convicted of manslaughter on the grounds of diminished responsibility.

Mr Warnes’ daughter, Susan Bellamy, told the BBC lessons must be learned to prevent such incidents happening again.

John Peters, who was 33 at the time, was under the care of the mental health services in Plymouth, but living in the community when he attacked and killed Roy Warnes who was living in a flat in the same building in Lipson Road.

Mrs Bellamy said Peters had prompted a number of complaints from neighbours.

She said: “He was ranting and raving at people going past, banging on doors and lighting fires in the flat.

“Nothing was done. No one went out to see him and no one called him in.”

An internal investigation by the Plymouth Primary Care Trust concluded his care had not been adequate or appropriate and that he had, in fact, had no care, treatment or supervision from the mental health services for a year before he killed Mr Warnes.

It said there were systems, communication and individual failures.

The independent inquiry commissioned by the South West Peninsula Strategic Health Authority to investigate the incident said in a report published on Thursday the killing could not have been predicted.

But it said it could have been prevented if the professionals responsible for his care had taken more assertive action.

The panel identified a number of shortcomings in John Peters’ care and made 23 recommendations, most of them directed to Plymouth Primary Care Trust.

The Trust said it had already put into place recommendations from the internal inquiry and would continue to learn lessons.

Ann James of the Trust said: “A number of individuals are no longer working in that team. We’ve change the management arrangements for that team.

“We now have much clearer policies and guidelines about how to work with individuals who are quite difficult to engage in some of our mental health services.”

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Independent Inquiry into the Care and Treatment of the Patient Known as P


P was born 24 June 1968 in Plymouth and brought up by his mother.  She married when P was about one year old and thereafter he took his stepfather’s surname.

P attended several primary and secondary schools where he said he was bullied.  When he left school he held a variety of manual jobs in the building trade and on the fishing boats but in latter years was unemployed.  He moved to live in the Saltash and Torpoint area of Cornwall, returning to live in Plymouth when he was about 28 years old.  His family had little contact with him.  His mother and stepfather were divorced when he was in his late teens and she later married his stepfather’s uncle.

He used drugs for some years and latterly regularly used amphetamine which, he told us, he injected intravenously.

P’s General Practitioner (GP) first treated him for a mental illness in 1993 when he complained of suicidal thoughts and depression.  In 1994, aged 26 years, he was referred to a Community Psychiatric Nurse (CPN).

In 1996 Dr Peter Urwin, Consultant Psychiatrist Cornwall Healthcare NHS Trust, saw him and described him as “this rather strange young man with primarily panic attacks”.  He was seen again following a normal EEG (electro-encephalogram) and a psychometric assessment, which demonstrated he was of low intelligence, although some of the tests he undertook were dependent on a certain level of social understanding and education which he lacked.  P did not keep his next appointment in July 1997 and no further follow up was arranged.

In April 1998 P was admitted to the Glenbourne Unit, Derriford Hospital, in the care of Dr Howard James, Consultant Psychiatrist, using section 2 Mental Health Act 1983 (MHA) from Charles Cross Police Station.  Dr Christine Dean and Dr Stephen Robinson completed the papers requesting admission for assessment.  He stated that he had recently ‘broken up’ with his girlfriend, with whom he had daughter, after almost ten years.  He was discharged on 1 May 1998, to be followed up by Ms Jeannette Callus, ASW.

From March 1999 until June 1999 P was on remand at HMP Exeter, charged with a serious driving offence and not complying with his bail conditions.  Dr Howard James saw him and arranged for his transfer to the Glenbourne Unit under section 38 MHA 1983 later converted to section 37 MHA 1983.  In September P went on section 17 leave and it was alleged that whilst in the community he administered a noxious substance and raped a fellow patient.

27 September 1999 – P was again remanded to HMP Exeter.  The victim was admitted to the Glenbourne Unit and was unable to give evidence, which delayed the court proceedings.

February 2000 – Dr James saw P in prison as the section 37/17 MHA 1983 had lapsed.  On this occasion he was fit and well and did not fulfil the criteria for further detention under the Mental Health Act 1983.

March 2000 – P was acquitted of the charges and as such became a ‘free agent’.  He failed to attend numerous appointments with either Ms Callus or Dr James.

November 2000 – P was charged with driving whilst disqualified and remanded on conditional bail at Plymouth Magistrates’ Court.

January 2001 –  Dr James completed a further court report in which he stated that Ms Callus was the key worker and that a CPN would administer the depot injections (a long acting injection of an anti-psychotic drug).  He went on to recommend that a Probation Order with a condition of treatment would provide the means of ensuring that P continued to receive treatment.

February 2001 – P was made subject of a Probation Order with a Condition of Treatment.  Ms Valerie Stewart, Probation Officer, wrote to Dr James informing him of the Order and requesting a meeting.  Mr Edward Read, CPN, became the allocated community nurse.

April 2001 – Ms Giulia Pridmore, Probation Officer, wrote to Dr James informing him that she was P’s Probation Officer and asked for an update on his mental health status and whether he had an allocated CPN.  Ms Callus and Mr Read undertook a joint visit to P to inform him that Mr Read would continue to give his injection and that there was no further need for social work input.

May 14 2001 – Mr Read administered a test dose of Zuclopenthixol depot injection when P attended the Nuffield Clinic without an appointment.

June 2001 – Dr James saw P at the Nuffield clinic on which occasion he requested his injection.  A further test dose was given.

August 2001 – Ms Jill Narin, Probation Support Officer (PSO) wrote to Dr James introducing herself as P’s new Case Manager, requesting an update on his mental state and enquiring if he had an allocated CPN.

27 September 2001 – Ms Narin saw P and wrote to Dr James informing him of this and that P was ‘low in mood’.

23 November 2001 – Mr Read wrote to Dr James informing him that he had not seen P since 17 August 2001.

7 January 2002 – P was sent a final warning letter because he was ‘in breach’ of his Probation Order.

22 February 2002 – P was arrested and appeared in court, charged with breaching his Probation Order.  The Order was revoked and he received a 12 month Conditional Discharge for the original offence of driving whilst disqualified.

25 April 2002 – Mr Paul McGarry (Housing Manager) telephoned Ms Callus about concerns regarding P’s antisocial behaviour.  A referral was made to the Gateway Service (the service which carried out assessments).  Dr Brian Pollard (GP) visited but was unable to see P.

3 May 2002 –  Ms Callus informed Dr James about P’s antisocial behaviour and he also received a letter from the GP who had tried to see P at home.  P’s ex girlfriend telephoned Gateway Service for advice because P wanted contact with their daughter.  On 7 May 2002 Dr James took the

GP letter to the team meeting with the intention of discussing its contents with Mr Read.

12 May 2002 – Another tenant, who lived at the same house as P, went downstairs at about 07.30hrs and saw that the panes of glass in the inner hall doors were broken.  He found Mr Warnes dead in the vestibule.  He telephoned the police who attended the scene.   P was charged with murder and pleaded guilty to manslaughter with diminished responsibility.  He was made subject to a Hospital Order with an accompanying Restrictions Order (section 37/41)



3 January 2001

P kept his appointment with Dr James at the Nuffield Clinic.  P was unkempt with poor concentration and appeared distracted at times.  He was still hearing voices, although they were not as bad as they had been 18 months previously.  He had not seen Ms Callus, as he did not feel he needed any help.  At the same time Dr James confirmed with her that she was prepared to continue as his key worker.  P told Dr James that he was taking his oral medication and self-administering his depot neuroleptic injection, sometimes every other day…

19 June 2001 –  Dr Julia Beresford, GP in the same practice as Dr Pollard, replied to Dr James’ letter.  She confirmed his oral medication as being Sertraline 100mgs and Olanzapine 15mgs nightly.  P told her he was having regular depot injections and she assumed they were being given by one of the CPN team.



2 January 2002 – A ‘breach’ letter was sent to P as he failed to keep his Probation Service appointment on 22 November, however this letter was withdrawn and Ms Nichols wrote again asking him to attend the office on the 7 January 2002.  He did not attend and was sent a ‘breach’ letter with another appointment for 11 January 2002, but he failed to keep this one as well.

1 May 2002 – Dr Pollard wrote to Dr James “Just to update you on this patient.  I was contacted by Jeannette Callus ASW, yesterday because of concerns that had been expressed by neighbours of P’s.  Apparently he was ‘flashing’ in the courtyard and also setting fires.  I see from the notes that in fact there has been no contact with P since August last year and he has not collected any medication since October 1st 2001…

Dr Pollard told us that he unable to understand why his letter was not ‘perceived’ as urgent, and he was sure that there was an implicit sense of urgency in his letter.  This was borne out by the fact that he stated that P had had no contact with anyone since August 2001 despite the treatment order, that things were beginning to fall apart, that P was setting fires, and that he had not collected any medication since October 2001.

7 May 2002 – Dr James told us he discussed the GP letter at the team meeting held that day, as the day before had been a Bank Holiday, and therefore the regular allocation meeting did not take place.  Mr Read was present, as was Ms Murphy, but he had no recollection of any discussion about P.

12 May 2002 – Another tenant who lived at the same house as P went downstairs at about 07.30hrs and saw that the panes of glass from the inner hall doors were broken, and found Mr Warnes dead in the vestibule.  He telephoned the police who attended the scene.  P was charged with murder.   P pleaded guilty to manslaughter with diminished responsibility.  He was made subject to a Hospital Order with an accompanying Restrictions Order (section 37/41).


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Victim’s daughter furious as killer reoffends — (BBC News)

6 September 2010

Peters (pictured) was using amphetamines before he killed Roy Warnes

The daughter of a postman who was killed by a psychiatric patient eight years ago has said she is horrified the killer has committed further offences.

John Peters killed 60-year-old Roy Warnes, of Plymouth, in May 2002.

On Monday, Peters, 42, from Southway in Plymouth, pleaded guilty at the city’s crown court to possessing amphetamine with intent to supply.

NHS Plymouth, which runs mental health services in the city, said it was not responsible for his criminal actions.

Peters had been using amphetamines before he killed Mr Warnes, who lived in a neighbouring flat.

I was absolutely shocked and horrified when I heard he had been arrested
Susan Bellamy

The 42-year-old, who had been diagnosed with mental health issues and prescribed medication, admitted manslaughter on the grounds of diminished responsibility.

An investigation two years later found Mr Warnes’ death could have been prevented if Peters had had more help from the mental health services.

After his conviction, Peters spent two years at a medium security psychiatric unit in Dawlish before moving to a low security hospital near Plymouth.

He was released into the community in 2005 but kept under NHS supervision.

Plymouth Crown Court heard on Monday that he was under the ongoing care of the psychiatric services. His case was adjourned for four weeks for a pre-sentence report and he was granted bail.

‘Hands on drugs’

Mr Warnes’ daughter said if Peters had been adequately supervised by mental health services it would not have been possible for him to offend again.

Ms Bellamy said: “I was absolutely shocked and horrified when I heard he had been arrested.

“I just feel they have not looked after him again.

“He’s got his hands on some drugs and it’s all leading back to what happened eight years ago.”

She added: “I really think they are not doing their jobs properly. They have let my family down and my dad would be turning in his grave.”

Dr Simon Payne, medical director for NHS Plymouth, said Peters had been subject to “regular and close monitoring” since 2005.

He said: “There is no suggestion that recent events are in any way linked to the care and treatment he has received from the mental health service.

“Although we monitor and maintain our service users in the community, we cannot be responsible for criminal behaviour that is not linked to an individual’s mental health.”

He added: “Mr Warnes’ death was a terrible loss for his family and friends and we are committed to doing all we can to make our mental health services as safe as possible.”