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BBC News
Last Updated: Thursday, 16 March 2006
SSRI Stories Summary – Daniel Gonzalez falls into the clutches of NHS mental health in his mid-teens. There, he is forced to take psychiatric medication which causes him extreme problems. He experiences serious motor difficulties from the meds and from withdrawal, and is only really better when he has been off meds for some time, which occurred only when he served his two year sentence at Dover. According to the Inquiry report, “No evidence of mental illness was found while he was serving his sentence in Dover.” However, even when staff realize that the medication is causing him extreme problems, they do not react as one might expect. One of his doctors wrote: “Historically if you look into Danny’s history he has never really done very well on a typical depot antipsychotic, which is the old-fashioned depot antipsychotic, he always had a lot of side effects. What we saw with the antipsychotic was that it brought down the agitation, it brought down the arousal, but we saw a man who had extrapyramidal symptoms: he was stiff as a board, it was quite a sight…” We know that Daniel was on various medications, including neuroleptic meds, but the specific drugs are not named prior to the incident. As is common for a person who has spent many years on these mind-altering drugs, Daniel goes through periods of aggression and serious thought disturbance. In the days leading up to the murders, he is clearly deteriorating but nobody intervenes.
After he murders 4 people the drugging really starts: As his doctor explains:
“600 Clopixol a week [which Daniel was being forced to take] is a mega dose. We decided that we would change over to a new antipsychotic, quetiapine, which has a very good side effect profile, and we started him on quetiapine. Around the time he was on the quetiapine he self-harmed and my concerns were that he was on a conventional dose of quetiapine, which is 750 mgs a day. It was not just the self-harm; the other problem was that he was unpredictable, hitting out at other patients and staff. Everything was fine and the next moment he would punch someone or, for example, he was having his dinner, he took the fork and went for another patient’s eyes. It was very lucky that he only managed to graze, otherwise he would have caused a lot of damage. We then decided to go on an unusual strategy of treating him on double the normal dose of quetiapine … I think some rationale we felt was that, given he was self-harming, was there a depressive element, so we also started an antidepressant along with that, venlofaxine [sic].
This poor man who experienced terrible reactions to his drugs is forced to take even more drugs which lead to more self-harm and unpredictable behaviour. Everybody is thrilled with the impact of the huge dosage increase and the addition of Effexor (venlafaxine, which the report misspells), claiming he has not been so well in years. Then he kills himself. News articles describe him as a psychopath and make no mention of the medications he was forced to take, and their affect on him.
‘Horror film’ cravings
A man who had Freddie Krueger fantasies has been convicted of the murders of four people he knifed to death within three days in September 2004.
Daniel Gonzalez, 25, from Woking in Surrey, killed two men and two women in Sussex and north London.
He was remanded in custody until Friday when he will be imprisoned for life for the “shocking and brutal” attacks.
Det Ch Insp Dave Cobb said unemployed Gonzalez wanted to be “remembered as a famous serial killer”.
“But I hope he is forgotten and that we only remember his victims,” he added.
“He admitted he was an individual intent on killing, [but] he was clever and manipulative and did not want to accept responsibility for what he did.”
The defence had argued Gonzalez should only be found guilty of manslaughter through diminished responsibility because voices in his head told him to kill.
Defence witness Dr Edward Petch, a psychiatric consultant at Broadmoor Hospital, said during the trial that he was a schizophrenic capable of “extreme, unprovoked and unpremeditated violence”.
Daniel Gonzalez armed himself with different knives for the attacks
The prosecution agreed he had a personality disorder, but said it was not a mental illness.
He was a psychopath who had wanted to carry out a campaign of murder of “at least 10 people”, they said.
Gonzalez told police he wondered what it would be like to be Freddy Krueger, from the Nightmare on Elm Street horror films, for a day.
Prosecutor Richard Horwell said he killed “because of the callous, cold person he is”.
“It is his very personality that led him to kill – disinhibited by a cocktail of drugs and alcohol.”
A jury at the Old Bailey in London took just 90 minutes to agree and convict him of murder on Thursday.
His victims were: Marie Harding, 73, who was stabbed to death in West Sussex; Derek Robinson, 75, and his wife Jean, 68, who were attacked in their home in Highgate, London; and Kevin Molloy, 46, who was murdered in a north London street.
Timeline of Gonzalez killings
Gonzalez had denied murdering them, but he did admit the attempted murder of two other people he stabbed in September 2004.
The men who survived his attacks were Peter King, 61, in Portsmouth, Hampshire, and Koumis Constantinou, 59, in north London.
Relatives of his victims cried and hugged each other in the courtroom’s public gallery as the verdict was handed down.
Judge Ann Goddard told the jury: “This has not been an easy case for you to listen to because the events have been so terrible.”
She said her only option was to give Gonzalez a mandatory life sentence, but that she still needed to fix the minimum term he will serve before being considered for parole.
Gonzalez’s mother, Lesley Savage, said her son had needed help but had not been able to get any.
Speaking after the murder verdict, Ms Savage expressed her “sincere condolences” to the families of the four murdered people as well as her son’s surviving victims.
But Ms Savage added: “Every time we asked for help for Daniel or Daniel did himself, we were told we would have to wait for a crisis to occur before he could get the help he needed.”
She said her son had been failed “by a system that is under funded and seems incapable of providing joined-up care over any period of time”, and resolved to not “let matters rest here”.
‘Independent inquiry’
The mental health charity SANE commented: “It is an insane system which cannot respond to the warnings of families and others before a tragedy happens.
“SANE calls for a red alert system whereby the mental health services and the police respond immediately when families report concerns about the safety of a psychiatric patient.”
Gonzalez was treated for seven years by North West Surrey Mental Health Partnership.
Its present incarnation, the Surrey and Borders Partnership NHS Trust said on Thursday that the murders were “not preceded by a history of violence and for that reason the trust does not believe his actions could have been predicted”.
Chief executive Fiona Edwards said: “The jury has rightly decided, in our view, that Mr Gonzalez understood what he was doing when he killed and assaulted his victims.
“Although he had been treated for mental health problems for a number of years there is no direct link between his illness and these shocking attacks.
“Despite the murder verdicts there will be a comprehensive and independent inquiry into Mr Gonzalez’s care and treatment by the NHS and we will cooperate fully with that inquiry.”
To view complete original report click here
An independent investigation into the care and treatment of Daniel Gonzales: A report for NHS South East Coast (formerly Surrey and Sussex SHA) and Surrey County Council
January 2009
(Page 4) 1. Introduction
1.2 On Wednesday 15 September 2004 Daniel Gonzales, 24, caught a train from London to Portsmouth and got off at Southsea. He approached an elderly couple, Peter and Janice King, and attacked Mr King with a knife. Mr King defended himself, and Mr Gonzales ran off. Later that day he killed Marie Harding, 73, in Southwick, Brighton. He stabbed her in the back, cut her throat and stole her purse.
1.3 Just after 5 am on Friday 17 September 2004, Mr Gonzales killed Kevin Molloy, 46, on Tottenham High Road, North London. He stabbed him in the face, neck and chest. At about 6.50am, Koumis Constantinou was woken by the sound of Mr Gonzales breaking into his house in Hornsey, North London. Mr Constantinou was stabbed several times before his wife came to his aid and Mr Gonzales ran away. At about 8am the same day, Mr Gonzales killed Derek and Jean Robinson at their home in Highgate, North London. He stabbed them in the throat. At the time he committed the murders and attempted murders he was 24.
(Page 11) 3.6 For the reasons set out in the body of our report, we are satisfied that Mr Gonzales suffered from schizophrenia, a severe and enduring mental illness, from the age of 17 when he was first admitted to hospital in February 1998, to the time of his death at the age of 27 in August 2007. His illness was atypical, and the lack of acute episodes or consistent and positive signs and symptoms after his discharge from hospital in 1999 made diagnosis difficult.
3.7 Many witnesses told us that, before the events of September 2004, Mr Gonzales was entirely unremarkable in his presentation and the nature of his contacts with services. It was suggested that there might be 40 people receiving services from the community mental health team (CMHT) whose profiles would match his. We accept the findings of the internal inquiries which took place soon after the offences and concluded that there were no missed clues that Mr Gonzales would suddenly exhibit such extreme and catastrophic violence. One cannot say, therefore, even with the benefit of hindsight, that Mr Gonzales should have been recognised as exceptionally dangerous. Although this may be a relief for those who worked directly with Mr Gonzales, it should be an uncomfortable finding for those providing services to people with this profile, as it makes it clear that something more than improved risk assessment is needed to reduce the likelihood of actions of this kind from people with this profile.
(Page 23) First psychiatric hospital admission – 1998
4.9 In February 1998, when Mr Gonzales was 17, he was admitted to the Abraham Cowley unit, an open psychiatric unit, for an assessment under section 2 of the Mental Health Act 1983 (MHA), after harming himself by punching a window. He was discharged by the Mental Health Review Tribunal before the assessment was complete, and returned to live with the Soanes. He continued to get into trouble with the police, and caused concern in all those dealing with him professionally, who believed that his mental health was deteriorating. Although he was living with the Soanes, he was spending a lot of time at his mother‟s. She told them he was talking loudly to himself at night.
Strategy meeting and second psychiatric hospital admission 1998 – 1999
4.10 In July 1998 Mr Gonzales became 18 and had to leave the Soanes. He moved to live with a new carer, Steve Price. He continued to cause concern to those working with him, through his apparent symptoms of illness, drug taking, lack of engagement and continued involvement with the police. On the 14 September 1998 representatives of social services, children’s services, youth justice services, CMHT, aftercare accommodation services, and Mr Price had a senior strategy meeting. The meeting identified his potential high risk of violence and/or suicide, and concluded that Mr Gonzales might never be able to live independently.
4.11 On the 28 September 1998, Mr Gonzales was admitted to the Oaktree clinic, a low secure psychiatric hospital, following a highly charged incident. His youth justice worker, John Humphries, saw him self-harming by hitting himself on the head with a saucepan and behaving in a threatening way towards Mr Price. He also caused criminal damage in the street before behaving threateningly towards the police, who restrained him and took him to hospital under section 136 of the MHA. Mr Gonzales stayed in hospital until April 1999, detained initially under section 3 of the MHA, then section 35, then section 38 and finally section 37. Dr Annear, the psychiatrist who cared for him during his first four months in the hospital was clear that he suffered from schizophrenia having given him a medication free trial. [This was probably a withdrawal reaction].
Visits family in Spain May 1999 to August 1999
4.12 While Mr Gonzales was in hospital his parents decided that a change of scene would give him the opportunity of a fresh start. So his father returned to live and work in Spain. He moved to Minorca. His son joined him in May 1999, returning to England in August 1999.
(Page 24) Deteriorating mental health and prison 1999 – 2001
4.13 Mr Gonzales returned to live with his mother and her partner, Stephen Harper. He was under the care of Dr Kidd, consultant psychiatrist in Woking. He was taking medication but suffered a severe dystonic7 reaction. As a result his medication was changed in February 2000. He continued to hear voices; to take street drugs, although to a lesser extent; and to get in trouble with the police. In March 2000 he moved out of the family home, at his mother‟s request, and became homeless. In April 2000, shortly before his twentieth birthday, he was arrested on charges of burglary and street robbery and remanded in custody to HMP Reading. In December 2000 he was given a two-year prison sentence for these and other, lesser, offences, which he served at Dover Young Offenders Institution. A report was prepared by Dr Ward Lawrence before the sentence. He observed no current symptoms of illness. He reported that Mr Gonzales had admitted manipulating the symptoms of his illness in an attempt to avoid being sent to prison on remand during an earlier assessment by Dr Lawrence in April 2000.
4.14 Personal and professional visitors were concerned that Mr Gonzales appeared to be mentally ill while he was in custody. He received anti-psychotic medication from the healthcare centre while he was on remand at HMP Reading. No evidence of mental illness was found while he was serving his sentence in Dover.
Released from prison, new diagnosis of no mental illness – 2001
4.15 He was released from prison on 30 April 2001 and remained on licence, supervised by the probation service, until 30 October 2001, initially living with his mother and Mr Harper. His offending behaviour improved considerably during this period on licence. His family continued to have concerns about his mental health, although when Dr Lawrence saw him in outpatients he felt that he did not suffer from any mental illness. Mr Gonzales was evicted by his mother in June 2001, slept rough for a period and was then found accommodation in a hostel.
Abnormal tonicity of muscle, characterized by prolonged, repetitive muscle contractions that may cause twisting or jerking movements of the body or a body part.
Returns home, assessed at A&E, becomes homeless, hostel place 2002
4.16 By January 2002 he was back home with his mother and Mr Harper. Mr Gonzales and his mother spent months seeking help, until finally Mr Gonzales was seen by his catchment area consultant psychiatrist, Dr Norman Weinstock, on 25 June 2002.
4.17 In July 2002 the police were called to an incident at the family home. They took Mr Gonzales to A&E at St Peter‟s Hospital, as he said that he felt unwell and needed accommodation because he could no longer live at home. He was not admitted to hospital, despite concerns expressed by staff at A&E. He was then homeless, living rough or with friends, until a hostel place was found for him in October 2002.
Caught shoplifting: supervision orders November 2002 to April 2003
4.18 Despite these difficulties Mr Gonzales kept out of trouble with the police during 2002 until November when he was arrested for shoplifting.
4.19 In January 2003 he was sentenced for the shoplifting, and given a six-month community rehabilitation order (CRO), under the supervision of the probation service. The probation officer was very concerned about his mental health. But Mr Gonzales was assessed by members of the community mental health team who thought that he was not particularly ill. The probation service continued to try and get him into work or education. Mr Gonzales continued to commit minor offences. He was given a 40-hour community punishment order (CPO) on 29 April 2003, again for shoplifting.
Returns to Spain May 2003 – December 2003
efore completing either the CRO or the CPO, Mr Gonzales went to stay with his father who was now living and working in Malaga. His family felt a change of scene would be helpful and might allow Mr Gonzales to find work.
4.21 He stayed with his father for two months, and then went to stay with his aunt in La Corunna, where he remained until late November 2003. He had no access to street drugs, but was clearly mentally ill. Mr Gonzales and his extended family believed that it was best for him to return to England to seek treatment. While he was still in Spain, on 26 October 2003 he wrote, but did not send, a long letter to his GP, Dr Kuzmin, expressing despair about his circumstances and asking for help. He acknowledged that he suffered from severe schizophrenia and asked to be admitted to hospital.
Cry for help letter and consequences December 2003 – April 2004
4.22 Mr Gonzales returned to England in November 2003. His mother and grandmother gave Dr Kuzmin’s locum the letter Mr Gonzales had written in Spain. The locum sent a copy, with a detailed two-page referral letter, to Dr Kidd, requesting an appointment for Mr Gonzales.
4.23 Mr Gonzales was seen in outpatients in January, March and April 2004 but was not offered an inpatient bed, despite his request to be admitted. It was not until April 2004 that he was allocated a care coordinator, Aloysius Kizza, who first wrote to him, offering an appointment, on 21 April 2004…
4.26 He had no contact with the police from the time he returned from Spain in November 2003 until 22 July 2004, when he was arrested on the warrant issued in June 2003 for failure to complete his CRO and CPO. He was remanded on bail. This prevented him going to Spain to see his father as arranged because the bail terms required him to surrender his passport and not seek other travel documents.
4.27 In court on 16 August he was fined £50 for breaching the CPO. There was no penalty for breaching the CRO, reflecting the relatively trivial nature of the original offences.
(Page 27)The murders and attempted murders September 2004:
September 11 Mr Gonzales went to a rave in London, returning home the following day
September 13 He gave himself black eyes by punching himself in the face then tried to harm himself by jumping down a flight of steps. He ran naked through the streets of Knaphill, Woking, before returning home.
September 14 He stayed at home
September 15 He travelled to Portsmouth and attempted to murder Peter King. He then went to Brighton and murdered Marie Harding before returning to Woking for the night.
September 16 He went to London
September 17 He murdered Kevin Molloy, Derek Robinson and Jean Robinson and attempted to murder Koumis Constantinou in North London. He was arrested.
Subsequent history: September 2004 – August 2007
23 September 2004 He was remanded to HMP Belmarsh
15 October 2004 He was transferred to Broadmoor high security psychiatric hospital
27 March 2006 He was sentenced to six life sentences for the murders of Marie Harding, Kevin Molloy, Derek and Jean Robinson and for the attempted murders of Peter King and Koumis Constantinou.
5.90 The purpose of this section is to gain an important prospective on Mr Gonzales‟ diagnosis from Broadmoor Hospital consultants who were able to observe him in a controlled environment. The only other time this quality of information was available was when Mr Gonzales was in Oaktree clinic under the care of Dr Annear.
5.91 Mr Gonzales was detained and treated in Broadmoor Hospital from September 2004 until his death in August 2007. The investigation heard evidence from both treating psychiatrists who carried out detailed assessments of his mental state. Dr Petch had initial responsibility on admission. When Mr Gonzales was transferred to Isis ward Dr Das took over responsibility. Dr Petch resumed responsibility when Mr Gonzales was moved from Isis ward to Henley ward.
Dr Das told us:
“Immediately on coming in, the view of Dr Petch, the admitting consultant, was that this is a psychotic illness, given the bizarreness of the offences, given the bizarreness of the self-harm, given that there is a clear history of him having presented with psychotic symptoms in the past, so he was started on an depot antipsychotic. Historically if you look into Danny‟s history he has never really done very well on a typical depot antipsychotic, which is the old-fashioned depot antipsychotic, he always had a lot of side effects. What we saw with the antipsychotic was that it brought down the agitation, it brought down the arousal, but we saw a man who had extrapyramidal symptoms: he was stiff as a board, it was quite a sight. When he came on Isis we thought this was not on, we had to do something; the side effects were so bad.”
5.92 In reply to a question about whether he was given the standard doses Dr Das said:
“No. It was 600 of Clopixol, which you will appreciate is a very high dose; 600 Clopixol a week is a mega dose. We decided that we would change over to a new antipsychotic, quetiapine, which has a very good side effect profile, and we started him on quetiapine. Around the time he was on the quetiapine he self-harmed and my concerns were that he was on a conventional dose of quetiapine, which is 750 mgs a day. It was not just the self-harm; the other problem was that he was unpredictable, hitting out at other patients and staff. Everything was fine and the next moment he would punch someone or, for example, he was having his dinner, he took the fork and went for another patient’s eyes. It was very lucky that he only managed to graze, otherwise he would have caused a lot of damage.
We then decided to go on an unusual strategy of treating him on double the normal dose of quetiapine … I think some rationale we felt was that, given he was self-harming, was there a depressive element, so we also started an antidepressant along with that, venlofaxine [sic]. We then started a mood stabiliser as well, sodium valproate. All these changes happened between August and October 2005. What we saw, I think it was with the quetiapine going up to 1500 that it temporarily correlates with a very dramatic improvement. From about September of last year [2005] Danny is a changed man….”
5.93 Commenting on the effect of the changed medication Dr Das said:
“The changes we have seen in him is that he began to talk with his primary nurse, he began to verbalise as to what was happening around the index offence, how he was feeling. We could relate to him in the sense that it was like coming out of a shell, he was warmer, it was like talking to somebody who was more normal, more warmth and smiles. He began to interact with other patients on the ward, he began to get into his usual interests of listening to music, watching videos….”
5.94 Dr Das was asked whether Mr Gonzales could be fabricating or concealing symptoms and whether someone who was not mentally ill could function on the high doses of medication that he was receiving.
“We had this discussion within the team, just to expand on this point, is this improvement in him just spontaneous, is this attributable to medication, is it that we are just medicating someone who doesn’t need to be medicated, for example. Talking to his parents, this is the best he’s ever been; they have not seen Danny so well since the age of about 15 to 16. This is a Danny they can relate to, they can talk to, a person who is organised in his thought process, able to talk about how he feels. Clearly there is improvement. There is indication that his presentation is better than how he was at about 16 to 17 years of age. That‟s one thing which would probably lead us to think that the medication is doing something.
The second point is the change in his mental state over a period of three months, from being extremely disturbed to a dramatic change, correlates very well with the initiation of medication treatment.”
“I think 1500 mgs of quetiapine would be extremely sedating, and if we were to give it to somebody, say, with normal dopamine levels in the brain, I think it would knock that person out.”
(Page 27) 9 August 2007 He apparently committed suicide at Broadmoor Hospital, aged 27