Re LTM
[2010] QMHC 26
•2 November 2010
MENTAL HEALTH COURT
CITATION:
Re LTM [2010] QMHC 026
PARTIES:
REFERENCE BY THE LEGAL REPRESENTATIVES IN RESPECT OF LTM
PROCEEDING NO:
0056 of 2010
DELIVERED ON:
2 November 2010
DELIVERED AT:
Brisbane
HEARING DATE:
29 September 2010
JUDGE:
Ann Lyons J
ASSISTING PSYCHIATRISTS:
Dr E N McVie
Dr J LawrenceFINDINGS AND ORDERS:
1. That at the time of the alleged offences on 19 December 2009 the subject of the reference the defendant was suffering from unsoundness of mind as described in Schedule 2 of the Mental Health Act 2000 (Qld).
2. That the defendant be detained as a forensic patient at the Sunshine Coast Network Authorised Mental Health Service.
3. That limited community treatment is approved to the Sunshine Coast Network Authorised Mental Health Service to commence immediately at the discretion of the treating psychiatrist, on the conditions set out in the submission of the Director of Mental Health.
4. That the reports of Dr Schramm, Dr van de Hoef and Dr Pathé as well as the transcript of these proceedings are to be provided to the treating team prior to the defendant’s appointment with Dr Lehmann-Waldau on 6 October 2010.
5. Dr Lehman-Waldau is to read those reports prior to the appointment on 6 October 2010 and is to seriously consider the recommendations of Dr Pathé at pages 4 and 5 of that Report.
6. A copy of these Reasons is to be provided to Dr Lehmann -Waldau.
7. A copy of these Reasons is to be provided to the Director of Mental Health.
CATCHWORDS:
MENTAL HEALTH – DECLARATION OR FINDING OF MENTAL ILLNESS OR INCAPACITY – where the defendant is charged with attempted murder and unlawful wounding of her 11 year old son – where evidence the defendant has a long history with mental health services – where evidence the defendant used illicit substances around the time of the offences – whether intoxication is an issue – whether the defendant was of unsound mind at the time of the alleged offences as described in Schedule 2 of the Mental Health Act 2000 (Qld) .
COUNSEL:
J Briggs for the Defendant
J Tate for the Director of Mental HealthS Vasta for the Director of Public Prosecutions (Qld)
SOLICITORS:
Legal Aid Queensland for the Defendant
Crown Law for the Director of Mental HealthThe Director of Public Prosecutions (Qld)
ANN LYONS J:
This is a reference by the Director of Mental Health in relation to LTM, the defendant. She is charged with two indictable offences namely attempted murder and unlawful wounding of her 11 year old son [T] on 19 December 2009. On 29 September 2010 I found that the patient was of unsound mind at the time of the commission of those offences. I indicated that my reasons for that decision would be published at a later date. These are my reasons for that decision.
The alleged offence
Both of the indictable offences are alleged to have occurred on Saturday 19 December 2009. [T] had fallen asleep in the lounge room on Friday 18 December and woke up on Saturday with a prodding sensation in his chest. He then saw that he was bleeding and that his mother was standing over him with a knife in her hands. It is alleged that the patient screamed at [T] words to the effect that “she couldn’t handle it anymore”. The defendant is then said to have started to stab herself in the chest with a knife before [T] disarmed her and put the knife in the sink. It is also alleged that the defendant obtained another knife and chased him around the living room while screaming at him. The defendant’s partner came from the bedroom and took the knife from her and moved her from the house. The defendant was taken to the Nambour General Hospital by ambulance and admitted to the Mental Health ward.
Sunshine Coast Mental Health Service File
The defendant has a long history with the Sunshine Coast Mental Health Service. She was first admitted to the Nambour Hospital in 2000 when she was 25 years of age in relation to drug use and has had a number of admissions since that date.
The Sunshine Coast Mental Health Service notes indicate that the defendant presented at the Emergency Department on 18 December 2009, the day before the offences, in the company of her mother. The notes indicate that in the previous weeks the defendant had suicidal ideation and wanted to kill herself with a knife. The defendant’s mother was voicing concerns about her ability to look after the children. The defendant was assessed by a mental health worker who noted the defendant’s mother’s report of a deterioration in the defendant’s mental state, as well as her agitation, poor sleep, poor concentration and memory together with feelings of stress. She was noted on that presentation to be worried and on the verge of tears. She denied delusional thinking but was noted to be guarded.
The defendant was seen by a psychiatric registrar at 1.00pm on the afternoon of 18 December who noted that she had had a diagnosis of a schizo-affective disorder but had had no medication for six months. He noted a history of 12 admissions; the last was for two weeks in August 2008. The history taken by the registrar also indicated that she had been reviewed by Dr Finlay two weeks beforehand. It was also recorded that [T] had rung the defendant’s mother two days earlier saying that the defendant wanted to kill herself. There was a history of multiple episodes of self-harm. The diagnosis made on that occasion was “no overt psychosis, possible personality vulnerabilities? Cluster A – differential diagnosis schizo-affective disorder”.
On 18 December 2009 the defendant was discharged with a script for Diazepam and the Department of Child Services was notified. There was a note that she was to be followed up by the continuing care team of the Nambour Community Mental Health Service over the weekend.
Ambulance Service Report
The Queensland Ambulance Service (QAS) were called in response to a report that a woman had injured her son and was harming herself. Their report indicates that she had lacerations and scratches on her chest, abdomen and neck. The ambulance officers were unable to obtain much information, but her mother, who was in attendance, advised them that she had been increasingly agitated over the past three days and had denied taking any drugs. The ambulance officers noted that on route to hospital she stated she wanted to harm herself and was agitated.
Emergency Department Notes
The Emergency department notes were recorded at the time of the defendant’s admission on 19 December 2009. The notes indicate that she had disorganised thought processes and believed she was a murderer. It was also noted that she was pressured in her speech. A request for assessment form completed on her admission noted that she had a diagnosis of schizo-affective disorder and alcohol abuse. The notes also recorded non-compliance with anti-psychotic medication for six months and the defendant’s intention to stab herself and set herself on fire.
The notes indicate that on arrival at the ward she was apprehensive, displayed symptoms of responding to internal stimuli and that she was listening to numbers. She was also noted to be trying to scratch her eyes out and said that angels had spoken to her. It would seem clear that the hospital notes of 20 December 2009 indicate that she was in a psychotic state. The psychiatric registrar found her to be uncooperative and agitated.
On 21 December 2009, there were further reports that she was hearing voices telling her to stab her son and herself in the eye. She was also apparently told that she needed to stab herself three times and set herself on fire. She made several odd comments, including that she could not eat because she would forget about hurting everyone.
On 22 December the defendant was assessed by Dr Finlay who reported she had used intravenous drugs in the week prior to her admission to hospital but would not indicate what they were. Dr Finlay noted she was thought disordered and expressed multiple delusions including persecution. The defendant was still noted to be psychotic on 23 December.
The defendant was hospitalised until early January 2010. It would appear in early January that she admitted to using amphetamines prior to her admission. The hospital notes continued to record her progress and on 10 January 2010 her behaviour is described as ‘bizarre’ and ‘unresponsive’ and that she was child-like and fatuous. Dr Finlay assessed her and did not consider that she was psychotic on that date.
On 11 January, however, Dr Finlay considered that there had been a marked depreciation in her mental state including formal thought disorder, ideas of suicide and seeing odd things. On 21 January she was again reviewed by Dr Finlay, who considered she was free of psychosis. She was subsequently allowed to leave hospital and was taken into police custody on 21 January 2010.
Urine Drug Screens
A drug screen conducted on 19 December 2009 at 6.30pm was positive for benzodiazepines, cannabis metabolites and amphetamine-like substances. Two subsequent urine drug screens on 23 December were negative for cannabis, but there were positive cannabis screens on 24 December and 26 December 2009 when she was under constant observation. All of the urine drug screens after 26 December were negative for cannabis and amphetamines.
Report of Dr Schramm dated 28 June 2010
In his report Dr Schramm noted the defendant’s progress in hospital as well as the fact that in the year preceding the alleged offences, in March 2008, she had an admission to the Mental Health Unit for about 11 days. She was placed under an involuntary treatment order (ITO). She was then followed up by the Community Mental Health Service under the ITO. Apparently she took Olanzapine pursuant to that ITO and was compliant with taking that medication until it ran out. It would also seem that she was having follow-up appointments with her GP who was responsible for monitoring her medication. She was also having fortnightly appointments with her case manager.
In July 2009, however, her GP left the practice and the defendant ran out of Olanzapine. She indicated to Dr Schramm that she felt fine for a couple of months off the medication but that she began to feel paranoid around August or September of 2009. In the weeks before the offences, it was clear that the defendant was becoming increasingly unwell and was having difficulty sleeping. She presented to Dr Finlay complaining of these symptoms. The defendant reported to Dr Schramm that she was generally managing to look after her children, although she was beginning to have paranoid feelings around October/November. She indicated she had no illicit substances in October or November 2009, but was not taking any medication.
In the week before the offences she reported using amphetamines and cannabis on 15 December 2009. She apparently had a day away from her children, caught up with some old friends and had two points of ice and between three and six cones of cannabis. The defendant reported to Dr Schramm that she felt unsettled after using these drugs and she did not sleep for the three days preceding the offence.
In the days before the offences Dr Schramm noted that on 17 December her mother was concerned about her agitated state and wanted to take her to hospital. On 18 December the defendant agreed to go to hospital because she had not slept for three days and was feeling stressed. She was given Valium at the hospital and sent home. On the night before the offences she took two of the Valium tablets but was still unable to sleep. She took her children to a Christmas party at the kindergarten that her younger twins attended and remembers feeling paranoid during the evening. She indicated that the children fell asleep in the lounge room around 10.00pm and her partner went to bed around 11.00pm. She felt too restless to sleep.
On the morning of the offences the defendant reported to Dr Schramm that she had run up the street at around 3.00am in her underwear; that her memory of the offences was poor; and that she heard an angry voice commanding her to get a knife. This was the same angry voice she had heard in 2002 which had told her to cut herself. She has no memory of actually cutting her son but she recalls her partner and [T] trying to get the knife away from her and that she was trying to stab herself. The defendant stated to Dr Schramm that her next memory was of the ambulance, police and her mother being at the house and her being taken to hospital. The defendant told Dr Schramm she has only a vague memory of being in hospital and stated that for the first couple of weeks in hospital she believed she had killed [T]. She also stated that she now believes she was uttering things such as the need to cleanse herself and to scratch her eyes out but she does not recall saying these words.
The defendant states that after a couple of weeks on the ward the angry voice stopped. The defendant told Dr Schramm that after six weeks on the ward she was discharged and taken into custody where she spent a month in the watchhouse and then the Women’s Correctional Centre. Since her release from prison she has been followed up by a case manager from the Community Mental Health Service. The defendant stated she resumed Olanzapine whilst in custody, but her medication has been changed to Abilify as the voices returned.
Dr Schramm’s opinion was that the defendant had recurrent episodes of quite florid psychosis featuring manic type disturbances over the past 10 years. He considered that those episodes also involved schizophreniform-type symptoms, including auditory hallucinations, bizarre delusions and delusions of reference. Dr Schramm considered that in between those episodes the defendant returns to good function but with chronic residual psychotic symptoms. Dr Schramm stated that the defendant reports that despite compliance, and despite refraining from illicit substances the psychotic symptoms persist but in uncommon frequency. He considers that the defendant’s illness is significantly exacerbated when she uses substances such as amphetamines or cannabis.
Dr Schramm’s view was that, given her apparent current ongoing psychotic symptoms in the absence of substance abuse, she seems to have an enduring psychotic illness which is not reliant on psychogenic substances. Dr Schramm considers that she had a marked deterioration of her mental state when off medication and with documented clear urine drug screens.
Dr Schramm considers the primary diagnosis is schizo-affective disorder and accepts the differential diagnosis of a persisting substance-induced mood and psychotic illness. He considered that the defendant would also have been diagnosed in the past as suffering from poly-substance amphetamine and cannabis abuse.
In terms of criminal responsibility Dr Schramm was satisfied that in the days leading up to the offences and for several weeks afterwards, the defendant was experiencing a florid exacerbation of her psychotic illness and that this would be considered a mental disease. He considers that she was experiencing command hallucinations at the time of the offence which she found she was genuinely unable to resist.
Dr Schramm also stated that the defendant also held various bizarre beliefs, many of which she believed justified her need to stab [T], although Dr Schramm noted that the defendant had given Dr Finlay various reasons for committing the offence. Dr Schramm considered, however, that the defendant’s grossly disorganised mental state at the time means that it should not necessarily be assumed that any one of those reasons was paramount in the moments leading to the acts. He considered those reasons gave an insight into her disturbed thinking at the time and how her psychosis affected her attitude towards what she considered she needed to do.
Dr Schramm believed that in the state the defendant was in she was completely deprived of the capacity to reason without any degree of sense and composure and therefore should be considered deprived of the capacity to know what she was doing was wrong. He also said that it was quite likely that she was unaware of the true nature of what she was doing. That is, she believed that no harm would come to [T], for example. He said she could also be considered to be deprived of the capacity to know what she was doing and that the passivity phenomena experienced around the time of the offences would also have deprived her of the capacity to control her actions.
It is clear that the issue of intoxication also needs to be considered. Dr Schramm considered that her urine drug screens indicated that she had used amphetamines and cannabis in the days surrounding the offences, not necessarily on the day of the offences, as those tests would indicate she had used amphetamines up to four days previously. Furthermore, cannabis has a longer elimination from the body and they could have been used much earlier. Dr Schramm considered that the use of substances, such as cannabis and amphetamines markedly exacerbated the defendant’s psychosis and it is reasonable to assume she would not have been so unwell if she had not used substances in the days before the offences. However he considered she would have remained unwell without the use of substances.
Report of Dr van de Hoef dated 16 July 2010
Dr van de Hoef gave a similar history to that of Dr Schramm, including a history of her treatment in hospital after the offences. Dr van de Hoef, in her report, considered that the defendant suffers from a chronic psychotic disorder, probably paranoid schizophrenia with the possible differential diagnosis of bipolar affective disorder with psychotic features. Dr van de Hoef considered that this mental illness had fluctuated in severity and had been characterised by disorganised thought and behaviour, delusional thinking and perceptual disturbances in at least one sensory modality. She also considered that the illness had a prominent mood component with episodes usually being manic in nature.
Dr van de Hoef considered the defendant’s mental illness has been apparent since at least 2000 and that her diagnosis has been complicated and changed as time has passed. She considers it co-exists with chronic alcohol abuse and probable dependence and intermittent substance abuse disorders. She considers the main substances being abused are cannabis and methamphetamines. Dr van de Hoef also considers the defendant is insightless in relation to her drug use and mental illness and that non-compliance with medication and non-compliance with follow-up as well as her continued substance abuse have compromised her engagement with Mental Health Services.
In relation to the question of unsoundness of mind, Dr van de Hoef believed that at the time of the offences the defendant was suffering from severe chronic paranoid schizophrenia. Dr van de Hoef stated that she had a history of relapsing, remitting mental disease with at least 10 major episodes of illness, which always arose in the context of medication non-compliance or intoxication with illicit drugs or both.
Dr van de Hoef considered that whilst the defendant’s treating team considered she had been relatively well in the six months prior to the offences, there were indications that the defendant may have had low grade residual or emerging psychotic symptoms on 18 December 2009 given she had had sleep disturbance and a week of suicidal ideation as well as perplexity and vagueness at the time. Furthermore, her mother had repeatedly tried to get her treatment during the week before the offences, and had found her with a knife in her hand that day and brought her in for assessment. Dr van de Hoef noted that within 24 hours of being brought in for assessment the defendant was floridly psychotic and unable to think or behave rationally. She noted that the defendant had stabbed her son and herself because of command hallucinations and bizarre delusional beliefs relating to angels. Dr van de Hoef considered the defendant remained in that state for four weeks afterwards.
Dr van de Hoef considered that the defendant’s report of cannabis and intravenous methamphetamine use on 14 December was significant but that the defendant had been thinking of suicide prior to taking those drugs. Dr van de Hoef considered that the defendant’s illicit drug use accelerated a relapse of her untreated schizophrenic illness at the time of the offences.
Dr van de Hoef does not consider that the description of the defendant’s presentation to Nambour Hospital following the offences fits well with acute intoxication. Dr van de Hoef considered therefore that her state of mental disease, namely a relapse of chronic schizophrenia, was triggered by a lack of treatment for six months and a single day’s use of cannabis and amphetamines five days earlier. Dr van de Hoef considered it was likely the defendant would have relapsed or, in fact had relapsed, even in the absence of illicit drug use.
In her opinion the defendant’s mental illness at the time deprived her of the capacity to know she ought not do the acts and possibly also of the capacity to control her actions given she needed to be forcibly restrained. Dr van de Hoef supports a defence on the grounds of unsoundness of mind.
Report of Dr Finlay dated 9 February 2010
Dr Finlay also outlined the defendant’s history of interaction with the Mental Health Services and her past psychiatric history, which had commenced in August 2000. Dr Finlay also noted that during her admission after the offences she had acknowledged she used intravenous drugs in the week prior to presentation. He noted the positive urine drug screen for cannabis, amphetamines and methamphetamines. Dr Finlay noted the acute onset of new and transient psychotic symptoms on her admission to hospital post the offence.
Dr Finlay also noted that her psychotic symptoms included but were not limited to command auditory hallucinations, passivity phenomenon, thought disorder and bizarre delusions. The defendant made statements in relation to her auditory hallucinations that the voices said to her to stab [T] and that the voices told her to stab her son in the neck three times and then her in the eye and then to set herself alight and jump in the pool and get shot. The defendant denied wanting to kill her son when she stabbed him saying, “I just wanted to relieve the pressure off everybody”. She also gave five other explanations which included that she stabbed him to save him from being tortured by her; that she stabbed him to protect him from bullies at school; that he wanted her to stab him; that if she did it her ex-husband would suffer because he didn’t have his son anymore and a further report that she stated she dreamt that [T] and his father were stabbing each other at the time. It would seem that her voices settled shortly after admission.
Dr Finlay has diagnosed the defendant in the schizophrenia spectrum. In his view it is schizophrenia, but it may be a schizo-affective disorder. An important differential diagnosis, which he considers is yet to be excluded, is temporal lobe epilepsy. Dr Finlay considered at the time of the offences the defendant was deprived of two relevant capacities, as outlined in s.27 of the Criminal Code 1899 (Qld) (the Code), namely the capacity to understand what she was doing and secondly the capacity to know she ought not do the act. Dr Finlay considered the capacity to understand what she was doing was severely impaired and probably absent. He considered the defendant was clearly thought disordered and she was not able to connect a series of thoughts logically; or rationally connect ideas. He believed that this was demonstrated in her six explanations she gave for allegedly stabbing her son, many of which lacked any logic or true understanding of the nature of the alleged act.
Dr Finlay, however, also considered there was an issue of intoxication as he believed there was evidence of intoxication delirium and this was the most likely explanation for the memory lapses displayed by the defendant and her confusion about the day on which the alleged offences occurred. Dr Finlay considered that the psychosis was certainly severely exacerbated by her drug use and that there was little doubt that the drug use precipitated the psychotic episode. He considered the defendant would not have committed these offences if she had not used the drugs. He considered that the defendant had lost the relevant capacities because of her drug use. He considered also that the drug induced delirium, intoxication or the drug induced psychosis alone would have caused her to lose these capacities.
In my view it is clear on the basis of the reports of the three psychiatrists outlined above that the defendant was clearly deprived of the capacity to know what she was doing was wrong and was therefore suffering from a deprivation of one of the relevant capacities at the time of the commission of the alleged offences. The only question which remains to be determined is whether the defendant was intoxicated at the time.
The Report of the Current Treating Psychiatrist.
The current treating psychiatrist, Dr Frieder Lehmann-Waldau, in a report dated 20 September 2010, set out the defendant’s current symptoms and the treatment she is currently undergoing. Dr Lehmann-Waldau indicated in his report that it was not entirely clear to him whether the defendant was suffering from a primary mental illness followed by illegal drug and alcohol use, thus exacerbating her symptoms; or whether she was suffering from illegal drug and alcohol use followed by psychotic symptoms, thus only resembling symptoms of a schizophrenic illness. Dr Lehmann-Waldau continued that he considered that the defendant was currently fit for trial and that she had an understanding of the nature of the charges and the nature of the court proceedings.
Dr Lehmann-Waldau considered that since her discharge from prison the defendant indicates that she has not had any further episodes of psychosis. He stated that she has continued to remain on her involuntary treatment order on bail conditions since January 2010 and that she has complied with her community-based ITO treatment conditions. He stated that she has not had any further hospital admissions and there has been no evidence of further psychotic episodes. Dr Lehmann-Waldau stated that the defendant has attended regularly at all her outpatients’ appointments with him and the psychiatric nurse and that she voluntarily submitted to urine drug screens. He stated: “We are not entirely clear about the arrangements for visits to her children and there remains concerns about a perceived lack of clear guidance regarding those.”
In terms of her current treatment she has regular visits from the treating team. She is on anti-psychotic medication such as Aripiprazole, 10 mgs daily and is prescribed Diazepam for the relief of anxiety. Dr Lehmann-Waldau stated that the defendant’s treatment plan is set up in liaison with the Community Forensic Service and said that there “seems to be a child safety plan in place with the Child Protection Liaison Officer and [the defendant’s] mother is aware of the procedures including the necessary risk management plan”.
Forensic Second Opinion of Dr Michelle Pathé dated 8 June 2010
In a very comprehensive report, Dr Pathé outlined her opinion in relation to the defendant’s current treatment and risk management. Dr Pathé made a series of conclusions and recommendations at page 4 of her report. In particular, Dr Pathé noted the obvious risks posed by the defendant’s apparent under-medicated condition, unsupervised access with her son, suboptimal monitoring of her mental state, as a consequence of her limited cooperation with the mental health team, and limited engagement of the defendant’s main supports, namely her parents. Dr Pathé also noted the potential destabilisation from future stressors and the likelihood of further substance abuse in the face of those stressors.
In terms of managing the risk, Dr Pathé believes consideration should be given to the following measures.
“· Every effort needs to be made to manage [the defendant's] illness with depot antipsychotics. Her history demonstrates the repeated failure of attempts to treat her with oral preparations. Her main objections to injectable formulations relates to concerns about adverse effects and past ‘guinea pig’ therapy, which seem amenable to reasoned and sympathetic discussion. She is now indicating her willingness to trial depot olanzapine as soon as practicable, but of course she hasn't exhausted other depot options. Given her current symptoms and preparedness to achieve better control of these, I would in any case consider an increment in her current dose of oral olanzapine. To do otherwise would risk further deterioration in her current presentation but would also risk conveying the impression of an unreceptive, or dismissive, MHT.
·[The defendant] requires regular and frequent monitoring by the Case Manager and treating psychiatrist, preferably along the lines of 'SNFP' review requirement regardless of the legal outcome at this stage. She has now undertaken to see her Case Manager on a weekly basis and they will make arrangements to ensure both are available. [The defendant] has also agreed for Mr Boa to meet with her mother and it is to be hoped that there can be some discussion around early warning signs and a clear contingency plan for the parents in the event that they have concerns. It will be important to reinforce that such concerns will be taken seriously and that there will be a low threshold for future admissions.
·[The defendant] is likely to be overestimating her capacity for enduring abstinence and has indicated at our interview that she would consider referral for drug and alcohol counselling if there are any lapses. In this case it would be far preferable to arrange random urine drug testing rather than testing on predictable dates.
·The current child contact arrangement is concerning and discussions with the mother should emphasise the importance of supervised contact at this stage. I understand that DOCS are involved with the case but they should be specifically advised of this high risk situation.
·Mr Boa is establishing a therapeutic alliance with [the defendant]. Every effort should be made to nurture this and continue to motivate [the defendant] to accept treatment and remain engaged.
·[The defendant] would benefit from further psychoeducation in relation to her illness, developing a better understanding of triggers and early warning signs, the contribution of illicit substances and formulating an emergency management plan.
·Any measure that diminishes this woman's social isolation should be encouraged. She has few social supports, her friends are mostly drug-users, and she has expressed a desire to associate with more responsible citizens. Her course may be an attempt to enhance her network but it may fall short of these expectations if it is predominantly online. A more extensive, pro-social network would also provide another source of monitoring for her mental state and functioning.
·As noted earlier, given the propensity for catastrophic violence when psychotic, there should be a low threshold for readmission in this case and her file should reflect this priority.”
The Views of the Assisting Psychiatrists
Dr Lawrence
Dr Lawrence’s advice was that I should prefer the opinions and advice and reports of Drs Schramm and van de Hoef as opposed to that of Dr Finlay. She considered that their opinions were expressed after thoroughly canvassing all of the information available to them and were based on their fairly lengthy interviews with the defendant. Dr van de Hoef considered that the defendant suffers from a mental illness of schizophrenia whilst Dr Schramm preferred a diagnosis of schizo-affective psychosis. Dr Lawrence stated that that mental illness has been long-standing, with the first episode in 2000 and its ultimate culmination in the very drastic and unfortunate events that led to her admission and the stabbing of her son in December 2009.
Dr Lawrence stated that whilst the defendant has had a number of admissions over time, her view is that the defendant’s condition has not been adequately assessed and understood or appropriately treated. She did not consider that she had been followed up and monitored with full awareness of the risks that her illness was bringing.
Dr Lawrence stated that whilst the illness commenced and in the early presentations occurred in a setting of polysubstance abuse, it is clear that there were difficulties in follow up and with compliance with the medication that was prescribed. Those difficulties continued over a period of time. Dr Lawrence considered that the symptoms were ongoing and that the symptoms of psychosis included command hallucinations. Those ongoing command hallucinations which gave instructions to carry out the acts, which she ultimately attempted on the 19 December 2009, dated back as far as 2003.
Dr Lawrence stated that there were consistent reports of the defendant’s very florid psychotic symptoms including delusions, gross thought disorders, disorganisation of behaviour, as well as the alarming hallucinations and passivity phenomena. Dr Lawrence indicated that those symptoms are usually thought to be characteristic of schizophrenia. She considered that the nature of the defendant’s symptoms were misunderstood and interpreted as evidence of a drug-induced psychosis.
Dr Lawrence considered that the defendant experienced those symptoms in the last few months of 2009 and she agreed with and recommended the approach of Dr van de Hoef. Dr van de Hoef thought that those symptoms were present but perhaps not revealed and were concealed from any routine inquiries that she was subjected to and not recognised as being present. The evidence however indicates that those who were relatives, such as the mother were aware of the presence of those symptoms. Her mother took her to hospital the day before these events seeking assistance however the urgency of the situation was not recognised at the time.
Dr Lawrence’s view was that the illness was so severe and the symptoms of the illness, namely the command hallucinations and the delusions that she was suffering at the time, were sufficiently severe to deprive her of the capacity to know and to understand what she was doing. She also considered that the illness was so severe that it may well have affected her ability or the capacity to control her behaviour because of the passivity phenomena. Dr Lawrence considered that the defendant had a defence of unsoundness of mind.
Dr Lawrence considered that a forensic order was necessary. She also considered that a significant issue which needed to be addressed was the defendant’s future management. Dr Lawrence was concerned that the current treating team have not had access to the forensic second opinion that was provided by Dr Pathé from the Forensic Mental Health Service on the 7th of June 2010. Dr Lawrence stated that in that report Dr Pathé sets out very clearly, concerns and the obvious risks posed by the defendant's apparent currently under-medicated condition. "Unsupervised contact with her son, suboptimal monitoring of her mental state as a consequence of her limited co-operation with the Mental Health team, and her limited engagement with the - of the patient's main support, that is, her family in her management and their understanding of it".
Dr Lawrence also noted that Dr Pathé’s Report also mentioned, "The potential destabilisation from future stressors such as the legal proceedings and embarking on higher studies and the likelihood of further abuse in the face of these stressors". Dr Lawrence stated that whilst those risks have been spelt out to the treating team it is concerning that three months later the current treating psychiatrist is still debating whether the defendant has schizophrenia or a drug induced psychosis.
Dr Lawrence’s view was that the forensic order is best placed in the district in which she is living as her main supports are primarily her mother and father. The defendant has been living in that area for a long time and her treatment and care should continue there. Dr Lawrence considered that admitting her to another area such as a medium secure area for a full assessment of the risks would not necessarily contribute to her ongoing needs.
Dr Lawrence stated that the defendant’s treatment needs are going to be life long and that the risks are likely to continue for some very considerable period of time. She considered that it was the management of the risk process which was the most important aspect and stated that the management needed to remain with the current Mental Health Service. She considered that there needs to be a proper education of those involved in her future care.
Dr Lawrence considered that whilst her views may seem critical of the treating team in her opinion, the severity of the defendant’s condition had not been recognised and her condition had been under treated. Dr Lawrence however also noted the difficulties faced by the treating team in relation to a person such as the defendant who has a tendency to non-compliance and non-engagement.
Dr Lawrence’s view was that there needed to be full education of the treatment team and a proper ongoing handover in any future time. Dr Lawrence stated that such a process could occur through the provision of transcripts and copies of the full reports being provided to the treating team. She also considered that there should be greater ongoing involvement of the Forensic Mental Health Service with respect to oversight or ongoing monitoring or guidance for the treating team given the difficulties in this case and the ongoing risks to the children. She considered that the clinicians should make reference to the necessity for supervised access to the children.
Dr McVie
Dr McVie stated that all three psychiatrists considered that the defendant had a serious chronic underlying mental illness, probably schizophrenia or schizoaffective disorder and they all considered she was so psychotic at the time of the offences to be deprived of at least the capacity to know she ought not do the act. Dr McVie also considered that particular reliance should be placed on the reports of Drs van de Hoef and Schramm and that their views should be accepted in relation to unsoundness of mind.
Dr McVie noted the complicating factor of the positive urine drug screen for cannabis and amphetamines on the 19th of December, as well as Dr Finlay’s view that she was delirious at the time. Dr Mc Vie considered, however, that the clinical evidence does not support any evidence of delirium and that Drs Schramm and van de Hoef gave very clear evidence that they considered her account of using amphetamines and cannabis a few days prior to the offence to be a reasonable and probably accurate account and to be consistent with the positive urine drug screen results at that time.
Dr McVie noted that both doctors considered that the defendant was most likely psychotic for some time in the lead up to the offences. Dr Schramm in his report details quite clearly that, "The defendant has chronic psychotic symptoms". And Dr van de Hoef in her oral evidence described her as being, "Masterful at hiding her symptoms and keeping them to herself".
Dr McVie considered that the overall evidence was that the defendant’s psychotic illness was re-emerging after at least three months without medication and prior to the use of the illicit substances. Dr McVie in particular took into account Dr van de Hoef's comment that the illicit drug use merely accelerated what was already a relapse of the schizophrenic illness which resulted in the severe episode of psychosis at the time of the offence.
Dr McVie considered that a forensic order is clearly indicated. Dr McVie also raised some serious concerns she had in relation to the issues of the defendant’s current management.
Dr McVie noted that the current offences involved the attempted murder of a child. She stated senior forensic psychiatrists in other jurisdictions consider that patients such as the defendant need a minimum of two years in a secure forensic facility in order to facilitate appropriate risk assessment and risk management plans and appropriate transfer back to community or to the District Mental Health Services. Dr McVie accepted that Queensland has a very different forensic service but indicated that this was a case about which she had serious concerns as the treating team does not appear to understand the diagnosis.
Dr McVie also raised concerns about risks and she described a previous case where the treating psychiatrist was accepting of the diagnosis of chronic schizophrenia, but other members of the treating team were less accepting of that diagnosis. Ultimately, the treating team's lack of acceptance of the diagnosis in that case resulted in lack of identification of symptoms of relapse, which eventually led to the death of a child.
It was Dr McVie’s view that the defendant does present high risks to herself, her children and to others. In particular, Dr McVie expressed concern about the difficulties that the Mental Health Service had encountered in providing appropriate management in 2009 in the lead-up to this offence. At that time, the defendant had been discharged from case management and her case closed. Dr McVie was also concerned that the current treating psychiatrist seems to continue to have problems in deciding on a diagnosis and deciding on treatment needs. Forensic services have been involved and the update report suggested that their advice has been drawn on in determining the treatment plan. Dr McVie shared Dr Lawrence’s concern that Dr Pathé's recommendations have not been followed.
Dr McVie considered that the defendant would benefit from a period of intensive assessment and management planning as an inpatient of a specialised forensic service. Whilst Dr McVie stated it need not be a lengthy period, she would advise that the defendant not be transferred back to care of a district service until the forensic services were satisfied that the treating team was sufficiently cognisant of the nature and depth of her chronic psychotic illness, the nature of her risks, and accepting of the need to put in place a specific and assertive management plan. Dr Mc Vie stated that a period of time in a specialised forensic unit would be advantageous to both the defendant and to the treating service to enable that service to have a period of time to familiarise itself with her treatment needs and to establish clear links between forensic services and the district services in the management of her case.
Dr McVie accepted, however, that in practical terms it would be very difficult to arrange. However, if it was not done Dr McVie could not see any other way of ensuring that a district psychiatric service could be forced to take responsibility. Dr McVie’s concerns related to the fact that the treating team do not have ownership of a diagnosis and the treating team are not committed to treating the defendant as they don't accept the diagnosis that Dr Pathe has provided to them
Dr McVie stated that:
“In my experience in community forensic services, there is absolutely no way to ensure that a treating team follows the directions of a community forensic psychiatrist, and it would be useful if the Director of Mental Health could give consideration to enhancement of policy in this area, and perhaps a review of whether a proper parallel forensic service with proper outreach to district services needs to be considered at this point. I think the community forensic services, even for special notification forensic patients where I believe a psychiatrist has to see an SNFP once every 12 months, is highly insufficient, particularly for cases like this.”
Dr McVie’s other concern related to the fact that there was a view that medico-legal reports were not part of the clinical file, and were not therefore to be placed on the clinical file. Dr McVie considered that such an approach was dangerous and that her advice would be to send a clear recommendation back to the Director of Mental Health that medicolegal reports done for Mental Health Court proceedings should be included in the clinical file so that all treating clinicians have very easy access to them. In her view the medicolegal reports done in relation to Mental Health Court proceedings should also be available as part of the mental health database (CINAH database) so that they can be easily accessed by clinicians who have to treat patients.
Conclusion
Having considered the reports of all the psychiatrists, as well as the views of the assisting psychiatrists, I am satisfied that the defendant was suffering from unsoundness of mind as defined within Schedule 2 of the Mental Health Act 2000 (Qld) (the Act) at the time of the alleged offences. I consider that whilst there is evidence of the defendant consuming cannabis and amphetamines 3 days prior to the offences, I am satisfied that the illicit drug use merely accelerated what had already clearly manifested as a relapse of her pre-existing schizophrenic illness. It was this relapse which resulted in the severe episode of psychosis at the time of the offence.
Given the seriousness of the offences and the ongoing risk to herself, her son and the community, I consider that a Forensic Order is clearly required. Whilst I note Dr McVie’s concerns in relation to the defendant’s current management and the non acceptance by the treating team of the defendant’s diagnosis, it seems clear that her treatment has been based in the community and her only supports are in that community. I also note Dr McVie’s concession that there are practical difficulties actually providing intensive assessment and management planning as an inpatient of a specialised forensic service in Queensland
I would therefore endorse the assisting psychiatrists’ views about the importance of the need to fully educate and engage the defendant’s current treating team. In Dr Lawrence’s view this could be ensured if there was a proper ongoing handover and by the provision of transcripts, as well as copies of the full reports, being provided to the treating team. She also considered that there should be greater ongoing involvement of the Forensic Mental Health Service with respect to oversight or ongoing monitoring or guidance for the treating team, given the difficulties in this case and the ongoing risks to the children. She considered that the clinicians should make reference to the necessity for supervised access to the children.
I also note and endorse Dr McVie’s concern in relation to the lack of ready access by the treating team to relevant reports which have been prepared for Mental Health Court Proceedings. I also endorse the matters of policy raised by Dr McVie and Dr Lawrence for consideration by the Director of Mental Health. In particular the concern that there is no way to ensure that a treating team follows the directions of a community forensic psychiatrist, and the need for the Director to consider whether a parallel forensic service with outreach to district services is required.
In my view, therefore, there should be the following orders;
ORDERS
1. That at the time of the alleged offences on 19 December 2009 the subject of the reference the defendant was suffering from unsoundness of mind as described in Schedule 2 of the Mental Health Act 2000 (Qld).
2. That the defendant be detained as a forensic patient at the Sunshine Coast Network Authorised mental Health Service.
3. That limited community treatment is approved to Sunshine Coast Network Authorised Mental Health to commence immediately at the discretion of the treating psychiatrist, on the conditions set out in the submission of the Director of Mental Health.
4. That the reports of Dr Schramm, Dr van de Hoef and Dr Pathé as well as the transcript of these proceedings are to be provided to the treating team prior to The defendant’s appointment with Dr Lehmann-Waldau on 6 October 2010.
5. Dr Lehman-Waldau is to read those reports prior to the appointment on 6 October 2010 and is to seriously consider the recommendations of Dr Pathé at pages 4 and 5 of that Report.
6. A copy of these Reasons is to be provided to Dr Lehmann -Waldau.
7. A copy of these Reasons is to be provided to the Director of Mental Health.
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