Re NEP
[2003] QMHC 6
•1 December 2003
MENTAL HEALTH COURT
CITATION: | Re NEP [2003] QMHC 006 |
PARTIES: | REFERENCE BY THE DIRECTOR OF MENTAL HEALTH IN RESPECT OF NEP |
PROCEEDING NO: | 0047 of 2003 |
DELIVERED ON: | 1 December 2003 |
DELIVERED AT: | Brisbane |
HEARING DATE: | 1 December 2003 |
JUDGE: | Wilson J |
ASSISTING PSYCHIATRISTS: | Dr D A Grant Dr J F Wood |
FINDINGS AND ORDERS: | 1. That at the time the alleged offence was committed, the defendant was of unsound mind as described in schedule 2 of the Mental Health Act 2000 (Qld); 2. Order that the defendant be detained as a forensic patient at The Park – High Security Program Authorised Mental Health Service for involuntary treatment and care. |
CATCHWORDS: | MENTAL HEALTH – DECLARATION OR FINDING OF MENTAL ILLNESS OR INCAPACITY – where defendant charged with one count of murder – where defendant has clearly established mental illness – where defendant suffers from schizophrenia – where defendant’s compliance with medication was variable – where defendant was seen by psychiatric nurse and psychiatric registrar on day of offence – where defendant discharged on same day – where defendant deteriorated into profound psychotic state – where defendant previously charged with murder of own child – where defendant is still psychotic – where no limited community treatment sought Mental Health Act 2000 (Qld), schedule 2 |
COUNSEL: | D Shepherd for the defendant |
SOLICITORS: | Legal Aid Queensland for the defendant |
WILSON J: NEP [“the defendant”] has been charged with the murder of a child [“A”] on 26 December 2002. He was her nephew, having been born on 2 February 1999.
The defendant was born on 2 December 1976. She has a clearly established mental illness, namely schizophrenia. She was previously charged with the murder of her own child, [“B”] who at the time of death was a little over a year old. With respect to that charge, she was found to have been of unsound mind at the time and ordered to be detained in the Wolston Park Hospital, Barrett Psychiatric Centre, by the Mental Health Tribunal in 1998.
She went to that centre and after some time was given leave to live in the community. She returned to Rockhampton where she had family. She resided with her de facto who was the father of the deceased child, B. She attended the local Mental Health Service. She had no further in patient admissions.
She was regularly seen by two case managers at the clinic and by a consultant psychiatrist [“Dr C”]. She was prescribed the medication, Risperidone. Her compliance with the medication was variable. There is no evidence that she was subject to urine drug screening or any form of blood testing.
She saw Dr C on 28 November 2002. This is what he said in a statement to police:
“Her condition at that time was quite stable. In particular, there was no evidence of hallucinations or delusions. I note that [the defendant] has never indicated any homicidal intent in any of her outpatient appointments.
Her medication was Risperidone, 4 mg per day. I wrote a further prescription for her on 28 November 2002, and arranged to review her on the 9 January, 2003.
For the duration of [the defendant’s] outpatient treatment, she was in general, compliant with treatment and outpatient visits. There were occasions when she missed appointments however, she did attend when reminded by her Case Manager.
On several occasions, I reduced [the defendant’s] medication as a consequence of side effects (galactorrhoea and sedation). This led to the development of auditory hallucinations over several days.
On each occasion, [the defendant’s] medication was increased back to the previous dosage with rapid resolution of her symptoms. At these times of experiencing auditory hallucinations, she never expressed any homicidal thoughts or impulses.”
The defendant’s relationship with her de facto broke up in March or April 2002. She returned to her father’s house. Her brother [“D”] lived there as well.
D had been in a relationship with the child A’s mother. In fact, the mother had been pregnant with A to someone else when her relationship with the defendant’s brother commenced. However, at all times he had treated A as his own son.
The relationship between A’s mother and the defendant’s brother, D, broke up. D lived with his father, that is, in the same house as the defendant. He continued to see A regularly.
A’s mother has said this:
“I have known [the defendant] for the last four and a half years. During the time I have known her she has never displayed any behaviour that made me think that she had a mental illness. I was aware that she had killed her son but believed that she would never do such a thing again as she had told me that she had to live with what she had done every day.
I trusted [the defendant] to look after my son [A]. She had been babysitting him regularly since he was born in February 1999. One week before she murdered him she had looked after him overnight and had taken him swimming.
When she brought him home the following morning her behaviour appeared normal. I did not see her again that following week.
On Christmas day my ex partner [D], [the defendant’s] brother picked [A] up to have him over the Christmas period.”
On Christmas Day the defendant went to Great Keppel Island by herself “to meet God”. On the way over on the boat she met a man, [“Mr F”]. They spent time together and spent the night together. She was returning to Rockhampton by boat when she jumped, fully clothed, from the boat into the water. This was a bizarre act. She was returned to the island where she spent another night.
The next day she went back to the mainland and Mr F took her to the hospital. At the hospital she was seen by a psychiatric nurse, [“G”], and a psychologist, [“H”], and subsequently by psychiatric registrar, [“Dr I”]. The nurse noted that on presentation she appeared to be affectively reactive, well presented with make-up on, and although she was not wearing shoes, she reported having lost her shoes in the ocean.
She expressed embarrassment and regret at what had happened in the previous 48 hours, including her behaviour on the boat and her liaison with Mr F. She spoke of her need to satisfy biological urges and became teary at times when speaking about her loneliness. She admitted to having experienced suicidal thoughts since her break up with her de facto, but she had never acted on these thoughts.
The nurse’s statement goes on as follows:
“[The defendant] discussed with some embarrassment, about experiencing what she perceived as voices. She laughed when asked whether she experienced perceptual disturbances, telling us that it was very unusual, she said “You’ll think I’m crazy if I tell you.” At the time she appeared to be trying to rationalise what she was experiencing. She said she heard an argument between the devil and Jesus, which she was stuck in the middle of. They were arguing for “the prize”, but when asked what the prize was, she didn’t know. While discussing this, her affect became quite fatuous and giggly. When we attempted to gain more information about this disturbance, she said the voices made her confused, but she was unable to elaborate any further.
When questioned about her medication, [the defendant] admitted to ‘messing around’ with it. She said she had stopped taking her Risperidone some months ago, but would take a few if she couldn’t sleep. She was unable to acknowledge whether the medication helped with the voices she reported hearing, although she believed that she needed to be on the medication. It was explained to her the importance of taking the medication as prescribed, and the impact this would have on her auditory hallucinations. She acknowledged this and agreed to resume treatment. She agreed to see [Dr I] for a medical review. [Dr I] reported that he would be available in ½ hour. [The defendant] agreed to wait in the Emergency Department to see [Dr I].
Both [H] and I were comfortable with the degree of engagement, and despite the relatively relaxed nature of the assessment, we were able to ascertain that she was not a danger to herself. She did not report any thoughts of self-harm or to others. She did not appear to exhibit any florid features of psychosis. She did not appear to be preoccupied with or responding to perceptual disturbances in the time we spent with her. She seemed to be making rational decisions regarding her treatment for her voices and her possible pregnancy. Her thought form appeared to be logical and goal directed and appropriate.
Subsequently, she saw Dr I and he said this:
“I reviewed her outpatient records and noted that she was last seen in the Rockhampton Mental Health outpatients clinic by her Psychiatrist, Dr [C] on 28 November 2002 and her Case Manager on 9 December 2002. She was taking Risperidone 4 mg per day and was doing well, living a almost normal life.
On examination, she presented as a well groomed, shy young indigenous woman, who greeted me with a smile. She was sitting calmly and comfortably in a chair and her eye contact was poor. She stated that she came to get her medication, Risperidone 4 mg daily and she needed something to avoid pregnancy. She reported that she had unprotected sex, two days previously. I asked her did she have children and she replied, ‘one, but he is deceased.’
After a while, she requested the presence of a female staff member because she was feeling awkward in a one to one situation with a male doctor.
Ms [“J”], the nursing manager on duty in the Emergency Department, subsequently joined us in the interview.
[The defendant’s] speech was normal and coherent and she was well oriented in time, place and person.
She reported that she had not taken her medication for a while, without being specific as to when [she] had ceased her Risperidone. She reported that she had lost her repeat script.
She said that she needed treatment for a couple of days as she had an appointment with Dr [C], Consultant Psychiatrist in early January 2003. She promised to take her medication regularly in the future.”
There was further discussion about emergency contraception. Dr I’s statement went on:
“She specifically denied depressed mood and her affect was appropriate. She had no neurovegetative features of depression or anxiety and had no indicators of suicidal or homicidal thoughts. No delusional material was evident in her speech. She denied perceptual disturbance.
She presented as being concerned about her illness, treatment and pregnancy. She was cooperative and willing to take medication and agreed to attend the outpatient clinic of Dr [C], her Psychiatrist. It was my opinion that she was not grossly psychotic and that she may have had residual Schizophrenia at her first presentation on 26 December 2002 at 12.00 p.m.”
She was discharged at about 1.20pm and taken home by acute care team staff members.
In retrospect, psychiatrists have expressed the opinion that she was probably psychotic at the time she was seen at the hospital. However, delusions can be internal to a patient and not be obvious to third parties.
She returned home. Her relatives did not notice anything especially untoward about her behaviour. However, some unidentified trigger caused her to deteriorate quickly into a more profound psychotic state. Within an hour or so of returning home, the offence was committed.
I will quote from the description of what happened which the defendant gave Dr Reddan, one of the examining psychiatrists. It is very little different from the report that she gave the other examining psychiatrist, Dr Varghese.
“She reported ... that after returning from the hospital she was playing with [A] and she read meanings into the games he was playing. She stated that she wondered, ‘What’s that all about?’ She stated that, ‘[A] made me clean things.’ She stated that it was as if she had to ‘clean up my mistakes.’ She stated that [A] ‘instructed’ her to place a curtain over the window so other people ‘could not hear us speaking with our minds.’ She stated that [A] also instructed her to place the mattress from her bed into the next room. She also stated that it was almost as if her own son, [B], was talking to her. She stated that [A] wanted her to play Scrabble, but when he would place a particular letter on the board she understood that the letter represented a word he was thinking of. She rather confusedly reported that she thought she was pregnant so that he ([A]) could return to the womb. However, at the same time she was thinking that he was [B]. ‘It was like get help, get the knife.’ She stated that a couple of nights before she had placed a knife from the kitchen in her bedroom drawer. She stated that she had been considering stabbing herself in the heart, but had not done so and her family were not aware that she had the knife in her bedroom drawer. She stated that she concluded from the letters on the board that, “it was like do it now”. She stated that [A], ‘looked at me like I should.’ She stated that she stabbed [A] in the chest with the knife ‘more than once’.”
It is clear on the psychiatric evidence before this Court that at the time of the killing she was suffering from a mental illness, schizophrenia, and that that illness deprived her of the capacity to know she ought not do the act. In Dr Varghese’s opinion, it also deprived her of volitional control. Accordingly, this Court finds that she was of unsound mind at the time of the offence. There is no question - a forensic order must follow in this case, and it must be for her detention for involuntary treatment and care in The Park High Security Program Authorised Mental Health Service.
The question of dangerousness looms particularly large. It should be recorded that the death by stabbing of two small children is extraordinarily rare. Dr Varghese said that in his many years of experience in Queensland and Victoria he had not come across such a case. Dr McVie, who is the treating psychiatrist, had reviewed the literature and she, too, could find no similar case.
The defendant is still psychotic. In the words of Dr Reddan, there is a grandiosity about being psychotic. There are issues of compliance with treatment and, in the words of Dr Varghese, she has a disarming childlike presentation which masks her dangerousness.
Limited community treatment in any form has not been sought, and it is not approved.
She is presently receiving Clozapine, which is an oral medication, and she is undergoing weekly blood tests to ensure that she is compliant with this. I note, however, that Drs Varghese and Reddan are both of the view that depo medication would be appropriate. Dr Varghese said he would not be prepared to treat her without it, and Dr Reddan considered it was necessary even in a high security unit.
The question of limited community treatment is, of course, a matter for periodic review by the Mental Health Review Tribunal. On present indications, it will be many, many years before she becomes eligible for such treatment, if she ever does. Any limited community treatment will require the strictest of monitoring as to her level of dangerousness and her level of compliance with medication.
I record that I have received into evidence the sworn statement of the child’s mother. This is evidence of observations of the defendant in the time leading up to the offence, and I treat it also as a victim impact statement.
This is an extremely disturbing case. It is an extremely sad case. The finding of the Court must be that she was of unsound mind within the meaning of the Mental Health Act at the time of the offence; and the Court orders that she be detained as a forensic patient in The Park High Security Program Authorised Mental Health Service for involuntary treatment and care.
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