Re RMA
[2011] QMHC 17
•7 October 2011
MENTAL HEALTH COURT
CITATION:
Re RMA [2011] QMHC 17
PARTIES:
REFERENCE BY THE DIRECTOR OF MENTAL HEALTH IN RESPECT OF RMA
PROCEEDING NO:
0265/10
DELIVERED ON:
7 October 2011
DELIVERED AT:
Brisbane
HEARING DATE:
24 August, 30 September 2011
JUDGE:
Ann Lyons J
ASSISTING PSYCHIATRISTS:
Dr J M Lawrence
Dr E N McVieFINDINGS AND ORDERS:
1. That at the time of the alleged offence on 13 May 2010 the subject of the reference the defendant was suffering from unsoundness of mind as described in the Schedule to the Mental Health Act 2000 (Qld);
2. That the defendant be detained, pursuant to a forensic order, to The Park High Security Program Authorised Mental Health Service.
3. That Limited Community Treatment is not approved.
CATCHWORDS:
MENTAL HEALTH – DECLARATION OR FINDING OF MENTAL ILLNESS OR CAPACITY – where defendant charged with one count of murder– where at the time of the alleged offence the defendant was receiving treatment for schizophrenia – where evidence the defendant guarded his symptoms from the treating team – where evidence the defendant was suffering from paranoia, delusions and auditory hallucinations – whether the defendant was of unsound mind at the relevant time – whether a forensic order and limited community treatment is appropriate
COUNSEL:
J Briggs for the defendant
K Parrott for the Director of Mental Health
B Campbell for the Director of Public ProsecutionsSOLICITORS:
Legal Aid Queensland for the defendant
Crown Law for the Director of Mental Health
Director of Public Prosecutions (Qld)
ANN LYONS J:
Background
This is a reference by the Director of Mental Health dated 1 December 2010. The defendant “RMA” is charged with the murder of “the deceased” on 13 May 2010 at Geebung, Brisbane.
The charge relates to the death of the defendant’s step-mother at a house that she shared with the defendant’s father, and their infant son. The defendant was his father’s son from a previous marriage and also resided with them. He was 22 years old at the time. The deceased was the defendant’s stepmother and the infant who was 18 months old was his half brother. The father and the deceased had commenced a relationship in 2002.
The circumstances of the offence
The defendant has not spoken about the event and there is limited information as to what actually occurred on the day in question. It is clear that at about 10.30am the deceased spoke to her sister on the phone. Her sister heard the deceased talk to the defendant about him bringing a dog into the house and that his response did not seem “angry or aggressive”.
At around 11.30am the defendant rang his father’s workplace looking for him and when he was told he was not there he said he would ring back. At 11.45am he rang his father on his mobile and told him to return home from work as the infant had been injured and was covered in blood. The infant’s father could hear the infant screaming in the background. As he drove home he rang the house and told the defendant he wanted to speak to the deceased. The defendant said she was in the bathroom with the infant.
On his return to the home the defendant’s father found his de facto wife face down in the kitchen covered in blood, and his infant son also covered in blood, crawling on the floor. The baby was uninjured and taken to neighbours at around 12.40pm. Police and ambulance officers were called to the house. Police attended at 12.45pm. The defendant was seen to be armed with two large samurai swords and a knife. He also had blood on his face, limbs and clothing. Negotiations were commenced to try and obtain entry and the defendant was eventually subdued with a taser and forcibly disarmed by police. He had multiple lacerations to both hands which required sutures.
The defendant declined an interview with police, he indicated he wanted to sleep and would speak to them later.
Presentation at arrest
At the time of his arrest the defendant was a patient of the Prince Charles Hospital Mental Health Service and was subject to an involuntary treatment order. He had received a depot injection of Risperdal Consta the day before the offence and had been reviewed by his treating psychiatrist at the Nundah Mental Health Service. He was also prescribed Quetiapine but was frequently non compliant with that medication, including a couple of days prior to the offence. Whilst a serum drug screen performed on blood collected on 13 May 2010 was positive for cannabinoids it was negative for cannabinoids the following day. It is reasonable to assume that this was probably a false positive result.
On the day of his arrest the defendant was assessed by a registered nurse. A psychiatrist reviewed him on the following day. He was noted to be markedly suspicious, hyper-vigilant with restricted but hostile affect. He also appeared to have psycho motor retardation and thought blocking, though he may have been preoccupied by internal disturbance. He had little recall of events surrounding the offence or of having treatment for his hands. He denied committing the offence. He also denied any recent use of drugs and said he had not had cannabis for a long time. He had not taken any alcohol but admitted to the recent use of diet pills. He was transferred to the High Secure Unit at The Park on 14 May 2010 where his treatment has continued. He is still subject to an involuntary treatment order.
The defendant has been seen by three psychiatrists, Dr Amanda Voita, Dr Pamela van de Hoef and Dr Schramm who have all prepared reports.
Dr Voita has been his treating psychiatrist since his admission to the high secure unit on 14 May 2010 and first assessed him on 15 May 2010. She has seen the defendant in excess of 30 occasions. Dr Voita’s report for the purposes of this reference is dated 25 November 2010.
Dr Voita’s report
Dr Voita outlined the defendant’s past psychiatric history in great detail, including his contact with the Prince Charles Hospital, Logan Hospital, as well as the Belmont Hospital. The defendant was prescribed Ritalin when he was in grades 3 to 4 as he was having difficulty concentrating. He was then diagnosed with ADHD at age 10 and took Ritalin for about two years. His first episode of psychosis was recorded at the Logan Hospital on 12 December 2005. He was then transferred to the Belmont Private Hospital on 15 December 2010. Significant psychotic symptoms were noted at the time which included persecutory delusions, misidentification and self-referential ideation. At that time a urine drug screen was positive for cannabis and amphetamines. He was subject to an involuntary treatment order and was eventually discharged in late January 2006 and treated with Olanzapine.
He had a second admission to Belmont Private Hospital between 10 May 2006 and 15 June 2006, after a short admission to Rockhampton Hospital. He had been sent to Gladstone to stay with relatives to get away from the local drug scene. The defendant had a history of substance abuse dating back to the age of 14 including amphetamines and Ecstasy from the age of 16. The discharge diagnosis on 15 June 2006 states a diagnosis of schizotypal, schizoid and anti social personality traits. He was discharged on Risperdal Consta and referred to the Prince Charles Hospital for follow up and case management. He was referred to the public sector as his then treating psychiatrist, Dr Gill, considered that the defendant required intensive case management which could not be provided in the private sector.
At the time of his arrest the defendant was still being treated under an involuntary treatment order by the Prince Charles Hospital Adult Mental Health Service. He was considered to suffer from depressive symptoms at times and was treated with Efexor between September 2006 and April 2007. The defendant received cognitive behaviour therapy as well as intensive case management.
There was also a history of significant co-morbid substance abuse. His insight was noted to be limited and he reluctantly accepted medications and follow up. He had reportedly ceased use of amphetamines and cannabis in 2007 and the treating team considered that he had accepted that his drug use was linked to his psychiatric illness. There was a relapse after his medication was reduced in late 2007 and the dose was increased and Seroquel added.
The defendant’s mental state settled until February 2009 when his father became concerned about threats to harm the infant. His depot Risperidone Consta was then increased to 50mgIMI every two weeks and then decreased back to 37.5 in October 2009. Dr Voita noted that he was compliant with depot medication up to the time of the offences and the psychiatrist noted that he was ‘settled’ and there were ‘nil’ issues after his appointment on 12 May 2010.
At the appointment on 12 May 2010 with Dr Drew Richardson, Dr Richardson stated that the defendant had refused blood and urine drug screens and that he was always difficult to engage and was not forthcoming with information. Dr Richardson stated that the defendant had never disclosed any desire to hurt anyone and he was not aware that there were any weapons in the house.
Dr Voita stated that on his admission to the high secure unit the defendant was placed in the acute admission unit and was initially nursed in seclusion. He was observed to be suspicious, guarded and perplexed. She stated there was evidence of formal thought disorder and although he denied auditory hallucinations he appeared distracted and preoccupied. Dr Voita stated that his depot Risperidone was increased to 50mg fortnightly and oral Risperidone and regular diazepam were added to his medication regime. The defendant was nursed in an open ward after about a week.
On 27 May 2010 Dr Voita stated that she discussed the alleged offence with the defendant during an interview. He stated to her that:
“I was having a stressed out day … I had thoughts and voices which is a rare thing … it was just for the day … I had thoughts and paranoia and weird stuff – curses … I find it hard to talk about … I only had it for the day … it went away after the thing happened – a few hours after … voices inside my head … I was trying to protect myself from some curse … [The deceased] had something to do with the curses … she was doing a curse … I don’t know why.”
Dr Voita had a further discussion with the defendant in June 2010. Dr Voita stated that he said:
“it was just a sudden thing that happened. I don’t know why it happened … I only heard voices for a day … I can’t remember what they said – both male and female … they were many – not hundreds … they were trying to protect me from the curse … they came from inside my head, where else would they come from.”
The defendant discussed the voices again in a later interview on 15 June 2010. In this interview he reported:
“I heard voices … voices were there for a couple of days …I was worried about myself and my dad … I did not want to be a slave or get ill due to the curse …it was a voodoo curse – I did not want to be under it – I did not want to get ill mentally … voices stopped straight after the incident when they tazered me … I think they tazered my head …I was very confused and my brain was not working properly …tazer just put me to the ground …voices went away after my deed … I did a bad thing … I was just trying to protect myself.”
Dr Voita noted that at interview on 31 August 2010 that the defendant was shocked by the content of the court brief and stated that he did not remember killing the deceased and that he did not believe he was responsible for the offence, and indeed did not believe that she was dead. Furthermore, Dr Voita stated he had indicated he could not believe he would do such a thing and believed that it was the demons that either killed her or they had organised someone else to do it. Dr Voita stated that he maintained this position on subsequent interviews.
Dr Voita considers that given his impaired insight into his illness and his ongoing delusional ideas, they could be contributing to his interpretation and recollection of events surrounding the offence. She also considers memory impairment may be due to traumatic amnesia. Dr Voita concedes however that it is possible that the dispute of facts is not due to the presence of a mental illness.
In her report Dr Voita stated that on 31 August 2010 in her interview with him the defendant had commenced the interview by informing her that he had to give her a background to his life. During that interview he told her that a person called Jessica controlled his body and that at times she takes over and he forgets things. He stated that Jessica became more apparent after his 18th birthday and she takes over and it happens without warnings. At those times he feels like the third person and feels that she is talking to him from the back of his head and controlling his body. He also stated that Jessica suggested that “we have a child personality” and that a third voice appeared which he called “Child” and he stated that Child was a “smartass” and he jokes and talks all the time.
He also reported that there was another voice which he called “the Professor”. He would say to him how he should behave and would say wise things. He stated that around 2006 “The twins” also came along in a dream and that they “stuck around”. One twin was male and the other female. He also reported that since 2008, which he calls the “paranormal years”, he has had horrible nightmares. He stated that he would feel like he was being poked when lying on one side and that this was scary. This was when the twins started telling him about the demons. He said that the demons stopped about a week after his admission. He reported that through 2009 and 2010 he would often hear the demons screaming. They would make a scary sound and would tell him that the deceased was trying to kill his family but that he could do nothing about it.
Dr Voita stated that although the defendant appears superficially settled on the open ward he is noted to be entitled and demanding of staff at times and appears suspicious. He has subsequently admitted to the presence of a number of bizarre and persecutory delusions and to the presence of auditory hallucinations. Dr Voita stated that the history he has provided has not been consistent in terms of the timeframe for the symptoms. He also appears to minimise the symptoms and have a limited understanding of their relevance or that they might be signs of a psychiatric illness. She states that although he has not refused treatment he has questioned the need for his depot to be increased. She states that he has limited understanding regarding the effect of the offence on his father and the reasons that he does not wish contact with him.
Dr Voita stated that when the defendant was confronted in July 2010 about the positive blood toxicology for cannabis, he was adamant that he had not consumed any cannabis in the preceding three years. During the interview in July he also expanded on a number of delusional beliefs that he had, including believing that the Nundah Mental Health Service was cursed. This belief was based on the fact that he had pains in the chest when he went there and because the deceased had visited there a few times. He stated that he believed the deceased was responsible for the curse and that the pains meant that he would die. He also believed that the deceased had put a curse on his dad and he believed that his dad and the infant would die also. He reported that on the day of the alleged offence the voices were screaming, telling him to do something about the curse. He stated that he realised now that he should have walked away and that he could have gone to his mother’s house.
Dr Voita stated that the defendant refused a trial of Clozapine due to his limited insight and that whilst he was trialled with a combination of aripiprazole, it has not resulted in a resolution of his psychotic symptoms. Despite another request to try Clozapine he has refused and he has been increasingly asking to cease his Risperidone.
Dr Voita reported that the defendant’s mother said that she believed he had ceased using drugs some years previously. She said she had been in touch with him in the days leading up to the offence and he had not voiced any unusual beliefs to her and she believed he was doing okay. She stated that about 18 months previously he had spoken to her about hearing voices and said that he had tried to block them out. The defendant’s mother believed that in that preceding three or four months prior to the offences he had refused to leave the house but was not aware of why.
Dr Voita interviewed the defendant’s father who indicated that the deceased had reported to him that in the days before the alleged offence the defendant was acting strangely. The defendant’s father also stated that he took the defendant to his appointment at the psychiatrist on the day before the offence. He stated that the defendant was anxious but this was not unusual when he attended appointments, because he was always concerned about being locked up. The defendant’s father stated that in the days leading up to the alleged offence he had some physical medical problems and the defendant had expressed concerns about this on the night before the alleged offence.
The defendant’s father told Dr Voita that he wondered if the defendant suspected he was being poisoned by someone, possibly the deceased. He stated that at times the defendant became concerned about food being poisoned and that when the infant had reflux he stated that the deceased had made him sick. The defendant’s father said that he had got used to the defendant talking about things such as a belief that they were all living in a ‘matrix’ with an implant and that people were controlled by someone else. He stated that the defendant had reportedly told him at times about hearing voices and that he believed that his father could read his mind. He also stated that the defendant talked to him about birds in the sky annoying him.
The defendant’s father told Dr Voita that in the months before the offence the defendant would not leave the house and he believed this was due to anxiety. The defendant’s father also reported that 12 months prior to the offence the defendant had said that he could slash the deceased’s throat. He stated that he could not remember why but he believed it was said in anger and he later apologised. The defendant’s father stated he was not aware of any particular animosity between the deceased and the defendant but agreed that they occasionally argued.
He also stated that prior to his son’s admission to the Logan Hospital the defendant believed he would be murdered and that the police were involved. He also stated that there was a time when the defendant wandered around the house with a baseball bat. He said that the defendant drank vodka but he only had two or three drinks, two or three times a week and he was not aware of the defendant drinking more alcohol leading up to the offence.
In relation to the day of the offence the defendant’s father told Dr Voita he was at the doctor in the morning and then went to work. The defendant then rang him at work that morning and asked him to come home because there was something wrong with the infant. He said he told the defendant to ring the ambulance and asked him where the deceased was. He stated that he had some difficulty now recalling the morning in detail but that when he arrived at the time the defendant looked like a statue. He said he grabbed the baby who was covered in blood but could not get to the deceased.
The defendant told Dr Voita that he had not used marijuana since he had been on an involuntary treatment order which would have been about four years previously. He had stopped using because he did not want to go back to the rehabilitation centre. It would seem that the defendant has not worked since 2006 and previous to that he had helped his father serving customers in a shop. He had been on a disability support pension since 2007 due to anxiety and stress.
Dr Voita considered that at the time of the alleged offence on 13 May the defendant was suffering from a mental disease. She considered that he was suffering from schizophrenia-paranoid type. She considers that the defendant has a severe longstanding treatment-resistant psychotic illness and that he has very limited insight into his illness and treatment needs. She stated that he has been avoidant of treatment and has actively masked his symptoms from his treating team and his family for a number of years. Dr Voita considered that at the time of the alleged offence the defendant also fulfilled the criteria of alcohol abuse and that he had a past history of cannabis which appears to have been in remission. Dr Voita also considered that the defendant exhibits some personality vulnerabilities with evidence of narcissistic personality traits.
Dr Voita considered that the defendant was responsible for the alleged offence and he was not impaired or deprived of the capacity to know the nature of the act, but he was however deprived of the capacity to know he ought not do the act and possibly the capacity of control.
Dr Voita noted in particular that a few weeks into the admission he reported very reluctantly multiple persecutory and bizarre delusions which pertained to the victim. He also admitted to other longstanding psychotic symptoms including auditory hallucinations, passivity phenomena, delusions of reference, and delusions of control. Dr Voita stated that the defendant has also reported that he believed that the deceased was putting curses on him and was trying to kill him, his father and his half-brother. She also stated that the defendant was avoidant of attending the Mental Health Clinic due to experiencing pain whilst being there and believing that the deceased put a curse on the clinic as she had attended there several times.
Dr Voita stated that the alleged offence appears to have occurred at a time when his psychotic symptoms had increased in severity and he was hearing multiple voices telling him he would be killed, that his father and brother were in danger and that the deceased was responsible for this. Dr Voita agreed with Counsel for the DPP, Mr Campbell, that there was nothing specifically linking the violence done to the deceased to his psychotic thinking. She also agreed that there was no evidence that on this particular day he was told by demons or one of the voices to kill the deceased. Dr Voita agreed also that there were no overt signs of his psychotic processes on the day and that his actions could have simply been an angry response to the deceased. In terms of whether the defendant was only psychotic on 14 May because of the violence he participated in, Dr Voita stated that it was a “remote possibility”. Dr Voita considered however that it was more probable than not that his actions were driven by his psychotic processes.
Dr Voita agreed that the defendant’s presentation of schizophrenia included the reference to multiple personalities and that this was unusual. She did not consider however that he had contrived his symptoms in any way or was “exaggerating or malingering” symptoms to accord with popular notions of what schizophrenia involved. In particular Dr Voita stated that the defendant was very reluctant to reveal that particular aspect of his life which related to the multiple voices, and indeed did not consider that having Jess talk to him was in any way part of his mental illness. Dr Voita also stated that the defendant had given a reasonably consistent account of these other personalities to all three psychiatrists.
Dr Voita also stated that the offence occurred at a time when his antipsychotic medication was reduced and he was non compliant with oral antipsychotic mediation. Dr Voita stated that his history states that there have been a number of relapses when his medications have been reduced. She noted that when previously unwell in 2007, the defendant threatened to harm is father and brother.
Dr Voita stated that if the defendant was not found of unsound mind she would support a finding of diminished responsibility and a charge of manslaughter.
Dr Voita considered the defendant was not currently fit for trial. She also considered that because he had been able to minimise and disguise his very severe illness for so long he would always be of concern. Dr Voita stated that his ability to mask his symptoms said a lot about his dangerousness in terms of his future management. His very guarded response to his treating team also meant that severe psychotic processes had been in place for a long time and were not picked up by them. Dr Voita stated that he is still not stable after 15 months on high doses of treatment, and indeed he reported that he had breakthrough conversations with “Jess” the day before the hearing.
At the time of the hearing of the reference on 24 August 2011 the autopsy report was not available. The proceedings were accordingly adjourned to allow for the completion of the report and to allow Dr Voita, Dr Schramm and Dr van de Hoef to consider that report.
Report of Dr Pamela van de Hoef
Dr van de Hoef stated that she does not consider that there is a dispute of facts except those arising from his mental illness. Essentially he said that he did not kill the deceased because neither he nor his other personality, Jess, was capable of killing. Dr van de Hoef also stated that she does not consider that intoxication was an issue.
Dr van de Hoef noted that the defendant’s description of his early life appears to indicate an overweight, miserable, socially anxious and isolated boy, with long term behavioural disturbance from middle childhood. She considers he may have developed psychotic symptoms from as early as 10 years of age. She considers that what may have been the imaginary friends of a troubled lonely boy appear to have developed into hallucinations and delusions around the age of 16 and a half and that they had only settled with antipsychotic treatment in recent weeks in the high secure unit at The Park.
Dr van de Hoef noted that the defendant spent a large amount of time describing his main and most recent other personality, namely Jessica. Dr van de Hoef stated that when he did so he became thought disordered. Dr van de Hoef noted Jessica was his friend from the age of 10 and co-habited his body from the age of 18. In his interview with Dr van de Hoef, The defendant said that he loved Jess, that she was real and that she controlled the body. He stated that Jess had started off as one year older than him but because she wanted to stay forever young she had stayed 19 years of age. He said that Jess would ask questions in her mind and wait for an answer. He stated that she had outwitted him and forced him to go against himself. He told Dr van de Hoef that she was a female trapped in his male body and that when she took over he lost half of his intelligence and had a memory lapse.
Dr van de Hoef stated that the defendant said that this was the case until about two weeks before the interview when quetiapine had blocked her. He stated that he experienced other voices, including ‘Chantelle’, the ‘Professor’ and ‘the twins’. The defendant told her that he heard demon voices from about 2008 in his father’s house at Geebung and that he considered the Nundah Mental Health Service was cursed. He also told her that the year before the offence was an extreme paranormal year where he experienced pains all over his body but could not tell anyone because they would not believe him. He stated in the week leading up to the event he did not sleep at all as he was hearing this constant female demon voice shouting at him, insulting him, calling him weak, pathetic and a coward which scared him “shitless”.
The defendant said he had been playing computer games since about 6am and that when his father left for work, the deceased started vacuuming and then there was a big memory gap. He stated that he was not capable of killing the deceased, and Jess could not do it either. When asked by Dr van de Hoef if he knew she was dead, he stated that he did but he said he did not know who killed her and that he couldn’t have and that he did not remember anything.
Dr van de Hoef considers that the defendant suffers from severe treatment resistant paranoid schizophrenia which had its onset at least in 2005. She considers that prior to 2006 he also fulfilled diagnostic criteria at various times for substance abuse. She states that in childhood he seems to have had a learning disorder and possibly a conduct disorder. As an adult she says he appears to have exhibited traits consistent with Autistic Spectrum Disorder, particularly in terms with arrested social development, extreme isolation and social withdrawal, as well as a very narrow range of interests and lack of empathy. Dr van de Hoef said that because he has been so psychotic for the last five years this is far from clear. She also notes that he probably has narcissistic personality traits.
In terms of the question of unsoundness of mind Dr van de Hoef considers that the defendant suffers from a state of mental disease, namely chronic paranoid schizophrenia, which was diagnosed in 2005 when he was 18, but may have had an insidious onset two years earlier in the context of cannabis and psycho stimulant abuse. She considers his illness has long, and quite possibly continuously, been characterised by marked paranoia and guardedness arising from a variety of perceptual disturbances (auditory and visual and possible somatic) hallucinations and a plethora of persecutory delusional beliefs including being poisoned, the house and clinic being cursed, and his stepmother being a witch. He also has a number of alter egos with Jess being the main one and at least four others.
Dr van de Hoef stated that he heard these voices and that he identified them as real people. Dr van de Hoef considers that it is likely that his abnormal experiences and belief truly rendered him out of touch with reality for years. She considers that on the day in question they reached a crescendo and he attacked the deceased to protect himself and possibly his little brother from poisoning and/or a curse. She considers he attacked her in response to command hallucinations and passivity phenomena or delusions of control when he suddenly came to believe Jess had taken over his body. Dr van de Hoef also considered that the letter ‘Jess’ had dictated which the defendant gave to Dr Schramm adds some more detail to the account of the offence.
In terms of whether his actions were driven by “anger and resentment” and were not psychotically driven, Dr van de Hoef agreed with Mr Campbell that that could indeed be the case, but that she did not think that was the case.
Dr van de Hoef considers that his guardedness and insightlessness prevented him from divulging any of this prior to the event. She considers he has a treatment resistant illness and that his compliance prior to the offence had been patchy. Dr van de Hoef agreed with Dr Voita that his guardedness and his masking of symptoms presented grave concerns for his future management.
Dr van de Hoef also noted his virtually complete social isolation in the few months prior to the offence was such that it would have made obtaining drugs impossible. Dr van de Hoef considers that even if he were to have smoked cannabis in the week before the offence that his severe chronic partially treated psychotic illness was such that it would have deprived him of the capacity to know he ought not do the act and probably of the capacity to control his actions regardless of intoxication.
In relation to the question of diminished responsibility, Dr van de Hoef indicated that she would support a finding of diminished responsibility. In terms of fitness for trial, Dr van de Hoef considered that given his delusional beliefs about Jessica they would impair his ability to instruct counsel and enter a plea. She considers that this unfitness is of a temporary nature.
In terms of future management Dr van de Hoef considers that the defendant is appropriately placed at The Park and he would benefit from continued treatment with anti-psychotics and antidepressants, and from continued psycho social rehabilitation including drug and alcohol counselling and illness education.
Report from Dr Michael Schramm
The third report was from Dr Schramm who interviewed the defendant on 11 May 2011. The defendant told Dr Schramm that he no longer heard demon voices which had been present for some years. He also stated that for most of his admission he has heard from none of his personalities, other than Jess. He now believes that Quetiapine blocks Jess from taking him over and that she can now only communicate in his dreams. Dr Schramm noted that even though the defendant says he accepts that he has some kind of mental illness he does not consider that Jess is part of the mental illness. The defendant is aware, however, that Dr Voita thinks otherwise. Whilst he denied fears for his safety and indicated that he feels quite safe Dr Schramm noted that he did let slip that he occasionally fears he is cursed.
Dr Schramm examined all of the witness statements, in particular, the defendant’s father’s description of his movements on the day of the offence, including the fact that he had been ill and that he considered that the defendant was possibly blaming the deceased for the fact that he had been sick. Dr Schramm noted that Constable Sarah Neil, one of the officers at the scene, described seeing the defendant on the back verandah holding a sword type weapon and that he stated “She attacked me first. I was defending myself.”
Dr Schramm stated that the defendant also explained to him that until recent months he had heard five separate voices or personalities which he said he heard from and that they took over his body at various times. He said most of these had been present only since 2007, but Jess, originally Jessica, was said to have begun as a voice heard as far back as the age of 11. He appeared to blame her appearance on the treatment he had with Ritalin for ADHD. Dr Schramm stated that the defendant would hear from Jess at times when he was prone to daydream. He reported to Dr Schramm that when Jess or one of the others took over he had memory gaps that lasted several hours.
Dr Schramm described that the defendant said he had smoked cannabis for the first time in years about four weeks prior to the offence and that in this period he reported hearing for the first time ever constant demonic screaming voices. He stated that in the weeks leading up to the offence he was highly anxious and frightened and worried about his father’s health, being concerned that the deceased was poisoning him. He denied to Dr Schramm that the voices were commanding that he hurt the deceased – at least he could not remember that they did.
Dr Schramm said that the defendant told him that in those weeks before the offence his mind was racing and he could not sleep. He stated that whilst insomnia had been a problem for years it had never been a problem to this extent. He told Dr Schramm that in the two weeks leading up the offence he had stopped taking quetiapine and temazepam because he considered that his insomnia was so established that it was no longer effective to take this medication.
In terms of the reason why he was feeling terrified in the two weeks prior to the offence, Dr Schramm noted that the defendant stated that there were several issues causing him concern and that one of those concerns related to him being “God” and in particular being worried that he would somehow be blamed for world events. He stated that those fears were not particularly new but his lack of sleep meant that he was more on edge than usual. He also talked of a relatively new experience of hallucinating, which he attributed to his lack of sleep.
He also noted that the defendant could not claim any real recollection of the day but recalls playing a computer game for a couple of hours in the morning. He remembers going to his room and that his next memory is talking to his father on the phone, with his father telling him that he was on his way home. He states that his next memory was being at the high secure unit.
Dr Schramm reported that the defendant says that following his admission to the high secure unit that he battled for four days in his mind to get rid of the demons and that they have since gone. He remembered in those first few days believing that he was in some kind of death match arena where people go to have blood sports. He says that he only realised he was in hospital after a week or so. After his arrival he remembered being told by Dr Voita that he was accused of killing the deceased and he remembered that he denied it, adding, “I still deny, I don’t think I’m capable …if I can’t remember then I know it wasn’t me.”
However he told Dr Schramm that about a week before the interview his mother had visited the deceased’s grave and he now accepts that the deceased is dead. Dr Schramm also stated that the defendant was keen to show him a written account which apparently had been dictated by Jess to nursing staff some months ago. The defendant told Dr Schramm that if Jess had not been blocked by the quetiapine she should have been able to tell him herself what she remembered of the day. That document is appended to Dr Schramm’s report, but it would appear to be an account of the moments after the killing and it states that he or Jess saw the infant with blood on him before finding the wounded victim. It seems that the person dictating the document seemed to be aware that demonic voices told her “to get the sword”.
Dr Schramm ultimately agreed with Dr Voita and Dr van de Hoef that the defendant suffers from a severe schizophrenic illness which had its onset in his mid teens and was likely to have been hastened by extensive substance abuse from age 14 until the age of 19 or 20. Dr Schramm noted that the unusual nature of the illness may be explained to an extent by the illness occurring in a man with a marked tendency, dating from childhood of retreating into fantasy and dissociation. Dr Schramm considers that he could not confidently apply a diagnosis of Autistic Spectrum Disorder but the defendant does have some features suggestive of this, such as marked social isolation, retreating into fantasy and limited interests. Dr Schramm also speculated whether some of the features could be also explained by other considerations such as schizoid personality type, a function of extreme sense of subjective difference/shame in his early life, having developed a psychotic illness early in one’s emotional maturation and even by some negative symptomatology of schizophrenia.
Whilst Dr Schramm accepts that there is evidence of entitlement and hostility conduct disorder he was averse to making a diagnosis of narcissistic and especially antisocial personality disorder, given that much of his entire experience has been ruled by psychotic understanding.
Dr Schramm noted that despite having been treated in hospital for over a year the defendant only shows a partial response to the medication. Whilst some of the active symptoms such as hallucinations have diminished, he considers he is left with residual delusional beliefs, although he appreciates that others now see them as morbid. Dr Schramm suggests that there is ongoing active psychosis in the form of continued referential experiences. He considered he is in some way treatment resistant.
Dr Schramm considers that there are many important issues and experiences that he does not have access to due to his ongoing guardedness. He suspects some of his guardedness may be driven by psychosis. Dr Schramm is not sure why the defendant is not giving an account of the offence in more detail, but considers that there does remain a great degree of guardedness.
In terms of criminal responsibility, Dr Schramm considers that the defendant was suffering from active and predominating psychosis as part of his schizophrenia at the time of the offence. He considers there was evidence that he was chronically unwell for a number of years and that this was hidden from others. He considers that he was experiencing an exacerbation at the time of the offences. Probably in the context of stopping his quetiapine and possibly precipitated by what had by that time been an unusual use of cannabis.
In terms of whether there is a dispute of fact, Dr Schramm considers that the defendant does not now completely rule out the possibility that he or someone in control of his body has killed the deceased. Dr Schramm stated that there is not a genuine dispute of facts that cannot be explained by mental illness or some abnormal psychological process. Dr Schramm does believe that there is a genuine dispute of fact. Dr Schramm considers that even if he had taken cannabis at some stage before the offence he does not consider it would have had an impact and that any impact on his capacities was a function solely of his chronic psychotic illness.
Dr Schramm stated that it was difficult to envision a scenario whereby the defendant’s preoccupying delusional beliefs and other psychotic experiences did not play a significant role in the attack but he does acknowledge the possibility. He states that the defendant now admits regarding the victim delusionally and that he regarded her as an acute threat on the day.
Dr Schramm acknowledged the issues raised by Mr Campbell in terms of the possibility that the defendant’s actions were driven by anger. However he stated he was satisfied that it was far more likely than not that he was in some way deprived of the capacity to know the wrongness of his actions and that this was driven by his psychotic processes. He also considered he may have been deprived of the capacity to control himself, but he does not know enough as to what happened on the day to say whether that is likely or not.
Dr Schramm also considers he would be of diminished responsibility.
In terms of fitness for trial, Dr Schramm considers that he could not sensibly instruct at the present time but that this should be seen as temporary at the moment. Dr Schramm indicated, however, that he held great doubts as to whether he would ever improve to a point where he breaks free of his delusional ideas.
Dr Schramm agreed with Mr Campbell that due to his ability to mask and his history of being guarded that one needed to be “forever cynical of his lack of symptomatology”. Dr Schramm stated that just because a person was able to participate in normal activities and appear normal that does not mean that psychotic processes were not at work. He considers that the defendant was motivated to conceal his symptoms particularly given the demons had told him he would be harmed if he said anything.
In terms of whether the defendant was participating in what Mr Campbell referred to as “delusional retrospective fabrication” Dr Schramm indicated that he did not think that was the case given the “plethora” of symptoms and psychotic experiences referred to by the defendant. In his view it was “unlikely” that the death was not a result of a psychotic event.
As to whether the defendant’s presentation with schizophrenia was unusual Dr Schramm indicated that everyone has a different presentation and that whilst the defendant referred to his experience of different personalities he does not consider that he has a multiple personality disorder but rather his psychosis was superimposed upon his underlying abnormal personality which was one that retreated into fantasy.
He considers that a forensic order is appropriate; that he is appropriately housed at the Park; and that he would be a candidate for Clozapine.
Autopsy Report
At the hearing of the reference the autopsy report in respect of the deceased had not yet been prepared therefore all reporting psychiatrists provided addendum reports following consideration of that report.
Dr van de Hoef noted that the autopsy report indicates that the victim sustained over 200 wounds comprising 53 stab wounds, 95 incisions and 67 abrasions. The injuries were inflicted with varying degrees of force both during life and in the peri or post mortem period. The cause of death was most likely from the main wound which completely transacted the main carotid artery and jugular vein. There were multiple extensive defensive injuries to both the deceased’s hands and forearms.
Dr van de Hoef stated that the autopsy report along with previously provided material including crime scene photos and witness statements leads her to make the following conclusions:
– that the deceased was the victim of a frenzied attack with a sword and knife in which she bled to death and was nearly decapitated
– Given the estimated time of death it is entirely possible the deceased was already dead when the defendant phoned his father
– Given that the deceased died from blood loss, in Dr van de Hoef’s opinion it is extraordinary that the defendant’s infant step brother was found with relatively little blood on him and no injuries. She speculates the infant was in or removed to another room before the attack.
– The fact that a lot of blood was found around places within the residence and the garden suggests that the defendant wandered around the home and garden after the killing.
In Dr van de Hoef’s view these conclusions only support her previously expressed view that the defendant was floridly psychotic at the time of the offences and suffered from a chronic severe treatment resistant schizophrenic illness. Dr van de Hoef thinks he had bizarre and persecutory delusional ideas about his stepmother and she speculated that he reacted in a way that may have resembled a psychotic re-enactment of one of the violent video games he habitually played. Further, he may have disassociated during or after the attack wandering around the home and yard, moving his step brother and then appearing “calm” when he phoned his father.
Ultimately Dr van de Hoef opined that in view of the enormous number of injuries and the ferocity of the attack the defendant’s state of mental disease utterly deprived him of the capacity to know he ought not do the act and the capacity to control his actions.
Dr Schramm also noted that the injuries outlined in the autopsy report and stated that whilst the report is consistent with a savage and sustained attack which would have continued well after the victim collapsed he could not see how it alters his previous report or oral evidence.
Dr Voita indicated that her opinion as stated in her previous reports remained unchanged in light of the autopsy report.
Advice of Assisting Psychiatrists
Dr McVie noted that the clinical evidence from all three reporting psychiatrists was consistent and that the defendant has a diagnosis of a severe treatment resistant paranoid schizophrenic illness. His psychotic illness has been diagnosed since 2005 and it developed on a background of difficulties in childhood, attention deficit hyperactivity disorder and schizoid or autistic features. Dr McVie noted the evidence of Dr Schramm that he has a tendency to retreat into fantasy and dissociation.
Dr McVie also noted that for the four years in the lead up to the offence, he had been treated on an involuntary treatment order with depot anti-psychotic medication. It's likely that there was minimal substance abuse during that period. Dr McVie considered in spite of his ongoing anti-psychotic treatment and management by the local district mental health service the defendant remained guarded and deluded and he didn't always divulge his psychotic symptoms to his treating psychiatrist. Dr McVie opined that this is not an unusual situation in general clinical practice.
Dr McVie’s advice was to accept the evidence of all three experts that at the time of the offence, the defendant was floridly psychotic. She opined that he was acting with persecutory delusions, associated command hallucinations specificity phenomena and he was deprived of the capacity to know he ought not do the act. She also considered that the evidence indicated that any dispute of the facts or lack of memory of the events arose from the defendant’s severe psychotic mental state at the time and that intoxication was not a factor.
In terms of future management Dr McVie stated
“A forensic order is clearly indicated and I, too, would advise that no limited community treatment is indicated at this time and I would advise that the treating team need to continue to exercise extreme caution when considered any limited community treatment for the foreseeable future.”
Dr Lawrence noted that the defendant has had psychiatric problems since childhood. She also noted that all three reporting psychiatrists were in agreement as to the diagnosis and that their opinions did not alter in oral evidence. Dr Lawrence considered that the defendant has a very severe and ongoing paranoid schizophrenia illness.
Dr Lawrence observed:
“… he was taken into custody immediately and was noted, at that time, to be perplexed, suspicious, guarded and internally preoccupied and seemed to be denying any positive symptoms of psychosis but he was immediately transferred to High Secure and Dr Voita, in her evidence, gave a picture of a man that remained guarded and not revealing his inner experiences for some time. And in fact, it took a long period of time before he began to reveal the extent of his inner disturbance.
She elicited, ultimately, extensive paranoid delusions about being cursed, believing his step-mother was poisoning [him] and possibly also his young half-brother… He also had belief in various entities, that is voices which he heard and which he'd been communing with over many years, one called, Jess, for instance.”
Dr Lawrence considered he was undoubtedly of unsound mind at the time of the offence. Dr Lawrence opined that he was deprived of the capacity to know what he was doing and was also probably deprived of the capacity to control his actions.
Dr Lawrence indicated that the prognosis for the defendant was poor She also considered that there are significant implications in respect of the dangerousness of the defendant which must be taken in to account in his future management. She concluded that the defendant required a Forensic Order to High Secure Inpatient Service and no limited community treatment is warranted.
Conclusion
I am satisfied on the basis of the three comprehensive reports of the reporting psychiatrists as well as the advice of the assisting psychiatrists that the defendant was of unsound mind at the time of the commission of the alleged offence on 13 May 2010. The clear evidence is that he has a long history of severe, treatment resistant schizophrenia and was floridly psychotic and experiencing command hallucinations at the time of the killing of his stepmother. I am therefore satisfied that at the time the defendant was deprived of the capacity to know he ought not do the act.
Is a Forensic Order required?
Given the seriousness of this offence there is no doubt that a forensic order is required. I agree with the submission of the DPP that the defendant’s guardedness and ability to mask severe psychotic symptoms means that his future management must be handled with extreme caution.
Counsel for the DPP noted in particular the following evidence from Dr Voita.[1]
“Does that suggest - that ability to mask what must have been severe---?---Mmm.
--psychotic symptoms, does that say anything about the dangerousness in terms of future management?--Yes, it does. It does.
And in terms of the ability to consider leave in future if there is a finding of unsoundness, does that call for extreme caution? --Yes, it does. It does. I mean, I'm still not fully satisfied that [the defendant] is disclosing the extent of his symptoms at this present time.”
[1] Transcript page 20 lines 5 -23.
I also note in this respect the evidence of Dr Schramm that forever one needs to be very, very cynical about the defendant's report of a lack of symptomatology. It has been established without a doubt that he can be very psychotic but not appear to be very psychotic. There is indeed a need for extreme caution.
I consider the defendant should be detained at The Park Centre for Mental Health. Limited community treatment should not be approved.
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