Re WCH

[2004] QMHC 26

MENTAL HEALTH COURT

CITATION:

Re WCH [2004] QMHC 026

PARTIES:

REFERENCES BY DIRECTOR OF MENTAL HEALTH AND DEFENDANT’S LEGAL REPRESENTATIVE IN RESPECT OF WCH

PROCEEDING NO:

0111/03

DELIVERED ON:

20 July 2004

DELIVERED AT:

Brisbane

HEARING DATES:

15 June & 13 July 2004

JUDGE:

Wilson J

ASSISTING PSYCHIATRISTS:

Dr J F Wood
Dr J M Lawrence

FINDINGS AND ORDERS:

1)   Finding that the defendant was not of unsound mind as described in schedule 2 of the Mental Health Act 2000 at the time of any of the alleged offences;

2)   Finding that the defendant is presently unfit for trial;

3)   Order that the defendant be detained as a forensic patient in The Park High Security Program Authorised Mental Health Service for involuntary treatment and care;

4)   Limited community treatment is approved in the nature of escorted leave (on and off the grounds of The Park – Centre for Mental Health), at the discretion of the authorised psychiatrist, on the following conditions:

      i.    that the defendant remain under the escort of a health service staff member or members nominated by the authorised psychiatrist for the duration of the limited community treatment; and

     ii.    that for the purposes of the limited community treatment, the defendant comply with the directions of the nominated staff member or members for its duration.

CATCHWORDS:

MENTAL HEALTH – DECLARATION OR FINDING OF MENTAL ILLNESS OR INCAPACITY – Unsoundness of mind – where the defendant is charged with various offences on eight discrete occasions – where the defendant suffers from schizophrenia – where the defendant has poor communication abilities – where there are differing expert psychiatric opinions as to whether the defendant was deprived of the capacity for control – whether the absence of rational motivation for offending behaviour is evidence of a deprivation of the capacity

MENTAL HEALTH – DECLARATION OR FINDING OF MENTAL ILLNESS OR INCAPACITY – Fitness for trial – where the defendant suffers from chronic paranoid schizophrenia – where the defendant is extremely violent and dangerous as a result of his illness – where expert psychiatric evidence supports extended detention in a secure mental health unit – where counsel appearing before the court did not challenge a finding of temporary unfitness for trial.

Criminal Code (Qld), s.27
Mental Health Act 2000 (Qld), Schedule 2

COUNSEL:

D Shepherd for the defendant
W Isdale for the Director of Mental Health
R Martin for the Director of Public Prosecutions

SOLICITORS:

Legal Aid Queensland for the defendant
The Crown Solicitor for the Director of Mental Health
The Director of Public Prosecutions

1. WILSON J:  The defendant has been charged with a number of offences allegedly committed between September 2002 and March 2004. There are references before this Court in relation to his mental condition at the relevant times.

1. Schizophrenia
   
   The defendant was born on 30 June 1977. He suffers from paranoid schizophrenia and has had numerous admissions to psychiatric hospitals since at least 1997.

1. In February 1999 the Mental Health Tribunal found him to have been of unsound mind at the time assaults committed in October 1997. He became a restricted patient under Part IV of the Mental Health Act 1974. Since the commencement of the Mental Health Act 2000, he has been reviewed periodically by the Mental Health Review Tribunal.

1. In March 2003 he was convicted of offences of wilful damage and imprisoned for two months. The Mental Health Review Tribunal reviewed his forensic order while he was at the Woodford Correctional Centre. Before his imprisonment he had been non-compliant with the conditions of his limited community treatment: in particular he had failed to keep appointments with the mental health service. The Tribunal revoked his limited community treatment. On his release from prison he should have been transferred to the Princess Alexandra Hospital because he was a forensic patient without any entitlement to limited community treatment, but instead he was released to a nominated residence at Annerley. The hospital was obliged to have him retrieved from the community, and so he was readmitted to hospital on 10 May 2003.

1. According to Dr Leong, who was his treating psychiatrist, he was mentally stable at the time of his admission to the Princess Alexandra Hospital, and there was no evidence of a relapse of his psychosis. He was, however, disruptive and uncooperative.

1. On 27 May 2003 the Tribunal again confirmed his forensic order without any limited community treatment, and recommended his future care in a more secure environment. He was transferred to a medium secure unit at The Park two days later, but returned to the Princess Alexandra Hospital on 8 July 2003 in order to accommodate an urgent clinical admission.  Assaults occurred while he was there on 26 August 2003 and 15 September 2003. In October 2003 he was returned to a medium secure unit at The Park.  He committed further assaults there on 7 November 2003, 27 January 2004 and 14 or 15 March 2004.

1. On 19 May 2004 he was transferred to the high secure unit at The Park, where he has remained.

1. Offences
   
   

   I shall set out the circumstances of each offence as gleaned from the police material and the reports of the three principal psychiatric examiners (Dr Geoffrey Leong, Dr Terry Stedman and Dr Frank Varghese).

1. Wilful damage between 27 and 28 September 2002

According to the police material, this occurred between 11.50 pm and 12.10 am in Orchid Avenue, Surfers Paradise. The defendant began upturning tables near a hotdog stand. Then with both hands he grabbed hold of a metal bar along the front of the stand and pulled it towards himself causing the stand to crash to the ground. Two microwave ovens, a refrigerator and numerous light bulbs were damaged. The defendant decamped on foot.

1. The defendant told Dr Leong he was angry at the time.

1. Two counts of serious assault of a police officer on 30 September 2002

According to the police material, the defendant attended the Cavill Mall Police Post in Surfers Paradise to surrender himself for damaging the hotdog stand. After looking for about 20 minutes, an officer told him he could not locate a complaint and asked him to leave. He refused. The officer asked for assistance from a more senior officer. The first officer again asked the defendant to leave and asked if there was anyone he could ring to come and get him. The second officer asked if he wanted to go to the Salvation Army. The defendant started speaking of being molested as a child. He punched the first officer in the head three times in quick succession. When the second officer came to the assistance of the first, the defendant kicked him on the leg with heavy boots he was wearing. Then he punched the first officer in the back. One of the officers sprayed the defendant in the face with capsicum spray, and after some further struggle he was restrained and handcuffed. 

1. During an admission to Princess Alexandra Hospital in May 2003 the defendant told Dr Leong that he had voluntarily taken amphetamines prior to the incident and that he was unable to recall any details of the event because he had "blacked out". He said he was unable to confirm or deny that he had assaulted the police officers. 

1. Dr Varghese examined the defendant at The Park on 5 April 2004. The defendant told him that he went to the police station of his own accord "to check if there were warrants against [him]". When he was about to leave the police station, he had a “black out”. When he woke up from the black out, “there was a gun pointed at [him] and mace in [his] eyes”. The police kicked him and he was handcuffed. The black out “just happened”. He did not describe ever having had such a blackout previously; he did not believe he had any head injury and he was unable to say how long he had been unconscious. He had no memory of having assaulted the police. At the time he had not been taking his medication for some months. He denied any illicit drug use around the time. He said he was hearing voices - women's voices "hassling [him]". He thought the voices were not about the police, and repeated that he had blacked out.

1. Failure to appear 15 October 2002

The defendant was required to appear at the Southport Magistrates Court at 9.00 am, but failed to do so.

1. According to the police material, at 2.15 pm that day he surrendered himself at the Brisbane City Mall Police Post. He said that he had failed to appear at Southport at 9.00 am because he had had no money to do so. He told Dr Leong that he had no money for transport to attend the hearing. 

1. Assault occasioning bodily harm 26 August 2003

The defendant was an inpatient in a psychiatric ward at Princess Alexandra Hospital when he assaulted a fellow patient.

1. According to the police material the defendant approached the complainant asking for a back massage. The complainant massaged his back for several minutes, during which time the defendant became verbally abusive. When the complainant went to leave the room, the defendant suddenly hit him on the face and continued to punch him in the face region five or six times until the complainant lost his balance and fell to the ground. The complainant required medical treatment.

1. There is no contemporary account of the defendant's version of this incident in the Princess Alexandra Hospital notes.

1. The defendant was subsequently transferred to The Park, and in interviews there he explained that he thought the complainant was trying to "crack on to [him]." He also said that "voices said he was going to attack [him]."

1. The defendant told Dr Varghese that he thought the complainant was going to throw water at him as he had done it to somebody else. (I assume this refers to the same incident. As I am about to explain, there were two assaults on the same complainant, and Dr Varghese does not distinguish between them in his report.)

1. Assault occasioning bodily harm 15 September 2003

The defendant assaulted the same fellow patient again.

1. According to the police material the complainant was returning to his room when without warning the defendant approached him and struck him with a closed fist five or six times to the face causing him pain and discomfort.

1. In an interview with Dr Leong the following day the defendant refused to discuss the incident. Dr Leong recorded that he was hearing no voices at the time.

1. After his transfer to The Park the defendant said in interviews that voices had said he was going to be attacked.

1. Common assault 7 November 2003

The defendant assaulted a male nurse at The Park.

1. According to the police material the complainant was working in the medium secure ‘Bandicoot Unit’ at The Park. About 5.50 pm he left the office there intending to go through a communal courtyard used by patients and leave via a gate. Whilst he was walking the defendant approached him, walked in front of him and hit him on the side of his face with a clenched fist. When the complainant turned his head as a result of the impact, the defendant hit him again with a clenched fist behind the ear, causing him to fall to the ground.

1. According to Dr Stedman (his treating psychiatrist at the time and subsequently), a period of overnight leave with the defendant’s brother had been arranged at the defendant's request for the following evening. The defendant repeatedly approached staff to cancel that leave or to attempt to alter the arrangements. Later, as the complainant (an elderly male nurse) was leaving the nursing station, the defendant approached him without speaking and punched him several times on the side of his head. When he was approached by the registrar on duty, the defendant explained, "I want to go back to jail; I don't like it here." When he was reviewed the next day he made a comment that the voices were gone and in all subsequent interviews he said that voices had told him to hit the next person who left the office. He subsequently explained that he knew it was wrong and asked if he could apologise. He also repeatedly approached the nursing staff office and bragged without remorse of the injuries he had caused.

1. As I shall explain, the defendant is charged with another count of assaulting (another) nurse. Of both incidents, he told Dr Varghese that he was unwell, that he thought the nurses were vampires and that he had taken Panadol and "spun out". When asked whether he was hearing voices he replied, "Yeah yeah," but did not go into any detail.

1. Assault occasioning bodily harm 27 January 2004

The defendant assaulted a second male nurse at The Park.

1. According to the police material the defendant returned to the secure unit after unsupervised ground leave within the grounds of The Park. It was a standard requirement in such a case that a patient submit to a search of his person to secure he had not secreted any items of potential harm to himself or others or unlawful drugs. On entering the unit he was escorted by the complainant and a female nurse to a secure interview room, where he became verbally abusive. He was then instructed to enter a locked bathroom with the complainant to allow privacy while he was searched. The complainant momentarily turned away from the defendant to unlock the door. The defendant stepped up to him with his arm raised and fist clenched. He punched the complainant several times in the face knocking him to his knees. When the complainant activated his duress alarm, the defendant stepped back and retired to a corner of the room and awaited the arrival of other staff.

1. Common assault 14 or 15 March 2004

The defendant's mental condition in relation to an assault on a fellow patient has been referred to the Court.

1. There is no police material available.

1. According to Dr Stedman the defendant was sitting on a bench with a fellow patient when he began throwing punches. When he was removed, he explained to the nurse involved that he was angry with the other patient because of an incident ten [sic] years previously. He explained to the doctor who reviewed him after the incident that the other patient had "set [him] up" and created conflict with him and his friends some years previously. After the incident he remained threatening and remorseless. The next day he asked staff to arrange for police to visit so that he could initiate a restraining order against a female involved in the incident in 1996 [sic]. Over the next few days he made comments about people taping what he said, ASIO, cameras and the like. When Dr Stedman attempted to interview him, he was surly and unforthcoming. He made a couple of comments about auditory hallucinations - comments which although not completely compelling were different from those he had made in relation to earlier offending. Subsequently he declined to discuss the incident. 

1. Dr Varghese spoke with the defendant about an incident involving another patient ["N"]. I assume it was the same incident. He told Dr Varghese that the other patient "wanted to set [him] up", that "he wanted to make [him] believe he had been shot in the head by a football player". He said "It was like when I was here ten years ago." He said he was quite unwell and believed the assault had occurred "all from [his] illness". He said the other patient was a friend of his but that he did not really trust him.

1. Unsoundness of mind

The Court must determine whether at the time of each alleged offence the defendant was deprived by his illness of any of the three capacities referred to in s 27 of the Criminal Code - namely, the capacity to understand what he was doing, the capacity to control his actions and the capacity to know that he ought not do the act. If he was so deprived, then it should find him to have been of unsound mind at the relevant time.

1. Overview of psychiatric opinion

It may be helpful to give a brief overview of the reporters' opinions before considering the evidence in more detail. They all wrote reports and gave oral evidence.

1. Dr Leong was the defendant's treating psychiatrist at the Princess Alexandra Hospital. His report which is dated 2 June 2003 deals with the defendant's state of mind in relation to the offences in September and October 2002. He does not support a defence of unsoundness of mind with respect to any of those offences.

1. Dr Stedman is the Director of Clinical Services at The Park.  He wrote reports dated 1 December 2003 and 20 April 2004 dealing with the defendant’s state of mind in relation to the assaults on a fellow patient at Princess Alexandra Hospital on 26 August 2003 and 15 September 2003 and the assaults of nurses at The Park on 7 November 2003 and 14 or 15 March 2004.  He also provided an update as the defendant’s condition in a short report dated 18 May 2004 and gave oral evidence.  He considered that there was insufficient evidence from which he could conclude that the defendant was deprived by his illness of any of the relevant capacities on any of these occasions.

1. Dr Varghese wrote reports dated 21 April 2004 and 6 July 2004 and gave oral evidence.  He considered all of the offences with which the defendant has been charged, and concluded that on each occasion he was deprived by his illness of the capacity to control his actions.

1. Schizophrenia is a psychotic illness which causes a disintegration of personality. At times there may be florid psychotic symptoms such as delusions and hallucinations; at other times there may be pervading negative symptoms of social withdrawal including psychotic anger and inability to communicate adequately with others. At times the illness may deprive the sufferer of one or more of the capacities in s 27 of the Criminal Code; at other times it may not affect those capacities or at most merely impair them. 

1. The defendant is an unreliable historian, something which may be related to his illness.  Further, he failed fully to communicate his thought processes at the relevant times to the reporters.  In some cases he spoke of hearing voices at relevant times, but he did not elaborate sufficiently for them to be able to conclude that the assaults were in response to such voices. 

1. Dr Leong

Dr Leong explained the circumstances in which the defendant was admitted to the Princess Alexandra Hospital in May 2003.  He told the Court that because the defendant was clinically well when he interviewed him about the offences in September 2002 and October 2002, he saw no reason to disregard what he told him entirely, and he concluded that when those offences were committed the defendant was of sound mind.  He said –

“Some people have a reasonable idea of – have some idea of what goes on when they’re unwell, some people don’t.  On the balance of the probability and the facts which he gave me I formed an opinion.  I thought that what he told me was what he could recall.”

(Transcript 13 July 2004 page 9)

When asked whether the defendant’s lack of communication was a feature of his illness, Dr Leong replied –

“Not entirely. I’ve had periods when I have been able to communicate with him.”

(Transcript 13 July 2004 page 10)

The defendant told Dr Leong that he damaged the hot dog stand because he was angry. Based on his self report that he had voluntarily taken amphetamines prior to the serious assaults on police officers on 30 September 2003 and had blacked out, Dr Leong concluded that at the time he was intoxicated with amphetamines, and so not of unsound mind. (See ss 27 and 28 of the Criminal Code.)

1. Dr Stedman

Dr Stedman said in his first report –

“Mental Disease or Natural Mental Infirmity:

Careful review of the available clinical records reveals that [the defendant] has repeatedly experienced episodes of auditory hallucinations, frankly thought disordered communications and bizarre and persecutory delusions.  The documentation of the substance misuse surrounding these episodes is generally poor, but it is clear that episodes have emerged in custody and after some weeks in secure inpatient settings where access to illicit substances is usually at a low level.  This suggests that it would be unwise to attribute all of his disturbance to personality and substance misuse problems.

[The defendant] is a tall and powerfully built man who has engaged in many instances of threatening and assaultative behaviour.  Some of this, is for intended for gain and for intimidation.  Some of the assaults appear to cluster within several weeks of intensely irritable behaviour where provocation is actively courted.  During these periods, there is often little or no evidence of psychotic symptoms or other evidence of mood disturbance.

Overall, I consider that [the defendant] suffers from Paranoid Schizophrenia as well as a variety of substance misuse disorders.  It is plausible, but by no means certain, that some if his recurrent angry assaults and property damage are a function of his psychotic illness.” 

1. In oral evidence, Dr Stedman was prepared to concede that the conduct was probably related to his illness and that the lack of communication was consistent with his illness, but given that lack of communication and the sparseness of the collateral evidence, he felt unable to express a concluded opinion about deprivation of capacity.  He said that there had been other assaults while the defendant was in The Park, and went on –

“…I’ve looked after [the defendant] for a long time before he went to high security or best part of a year anyway and most of the time he seems to be reasonably well in control of his behaviour but his assaults are a little bit mystifying sometimes.  Sometimes they’re quite understandable in terms of intimidating people or threatening people but other times they make no sense at all.  So – and – and sometimes he goes out of his way to provoke other people so that he has an excuse to – to – to hit them.  So – but – even adding all that into the equation I – I can’t find any strong support for an unsoundness of mind defence.”

(Transcript 15 June 2004 page 13)

1. Dr Varghese

Dr Varghese interviewed the defendant twice – on 5 April 2004 and 28 June 2004.  On the first occasion he said the defendant gave a quite matter of fact account without much elaboration and showed no emotional concern about his multiple acts of assault as he described them.  The defendant ascribed all his assaults to his “illness” but was not troubled at all about what had occurred.  Dr Varghese thought his affect was blunted to some extent although there were islets of reactivity.  There was no evidence or depression or anxiety.  Dr Varghese considered there was a subtle degree of formal thought disorder, particularly when describing his psychotic symptoms and noted ongoing descriptions of hallucinations as well as persecutory delusions, including of being photographed and “put on the internet”.  His insight was quite limited and superficial, and overall his judgment poor.  His cognitive functions were in tact.  On the second occasion the defendant was guarded, unco-operative and hostile.  He appeared to distrust Dr Varghese, showing boredom and contempt, and fixing him with a paranoid stare.  From time to time he looked at a male nurse who was present in a paranoid fashion.  Dr Varghese considered the defendant’s schizophrenia to be severe, and that despite treatment there was deterioration in his condition between the two interviews. 

1. In oral evidence Dr Varghese said that he thought the defendant has an underlying psychosis involving fear of interference with his body, but that despite the severity of his psychosis, there is a rational part of him – for example, a nurse had reported him on one occasion assaulting a nurse and then walking into the seclusion room without being asked to do so.  His hearing voices was not the predominant issue in the assaults. 

1. The defendant’s unreliability as an historian and his very limited capacity to describe what is happening to him are, in Dr Varghese’s opinion, aspects of his illness, and it will never be possible to dissect each individual assault with respect to his specific mental state at the specific time.  There was no motive for the assaults, which were a product of his psychotic mental state.  In Dr Varghese’s opinion, the defendant was deprived of the capacity for control on each occasion.  The following exchange between the Bench and Dr Varghese occurred during the hearing –

“Schizophrenia is an illness which is always present?-- 

Yes

In theory is it not the case that sometimes that illness causes the patient to be deprived of one or more of the capacities?-- 

Yes.

And at other times it doesn’t cause him to be deprived of the capacities?—

Yes.  Your Honour, are you talking about this particular person?

No, I’m talking in general?- 

Yes.

With respect to delusions, in general they can sometimes be present and sometimes not be present.  Is that correct?-- 

Delusions on the whole are present all the time.  The intensity to which a person experiences them varies.

And the intensity with which they’re experienced will impact upon whether there is an impairment or even a deprivation of capacities?-- 

Yes.

But is it your view that this patient’s schizophrenia is so severe that he is constantly deprived of the capacity of control?-- 

Now [sic] I don’t think he’s that severe.  I think there is an underlying psychosis with delusional ideas, delusional experiences, strange phenomena which he experiences, possibly chronic hallucinosis which don’t seem to play a big part in his thinking.  And certain cues in the environment, certain things that happen, trigger off the behaviour. 

All right.  Well-----?

So the absence of those cues are then – the extent to which you could say he’s deprived is debatable. 

Well is it the case that you haven’t been able to identify what the cues are? 

I don’t know what the cues are.

All right?—

I suspect it’s something to do with people’s – reading people’s body language.  He was paying a lot of attention to my body language. 

All right.  Well is it the case that there may have been instances when his delusions were of such intensity that he was deprived of the capacity of control?-- 

Yes.

But is it also the case that he may have engaged in such behaviour in circumstances where his capacity of control was not totally absent, may have just been impaired?—

I’m inclined to the view that it would be absent unless the assault was explained in some other way, like there was some motivated [sic]. 

Well is it the case that in your opinion it’s important if not essential to establish a motive for an assault if it’s to be explained in non-psychotic terms?-- 

In this particular man I believe so.

And why in this particular man?—

Because I think the psychosis – his psychosis is severe and constant.”

(Transcript 13 July 2003 pages 40-41)

1. Deprivation of Capacity for Control?

I accept that the defendant has a severe form of paranoid schizophrenia, and that his unreliability as an historian and failure fully to communicate his mental processes at the relevant times are aspects of his illness.  I appreciate that because of his communication difficulties, it may never be possible to isolate his mental processes on particular occasions (although I note that Dr Leong seemed not to support this conclusion).  However, this Court is obliged to consider his mental state with respect to each of the offences with which he has been charged, and cannot take a broad brush approach to what are in effect eight discrete questions as to his soundness of mind.  Dr Varghese’s conclusion that there was a deprivation (and not a mere impairment) of the capacity for control on the occasion of each assault rests on his assessment that there was not a rational motivation for any of the assaults. 

1. Even if that were so (and it may not have always been so – for example, the defendant’s explanation for one of the assaults in the Princess Alexandra Hospital that he thought the complainant was trying to “crack on to [him]” may have been mistaken but nevertheless not irrational), I am unpersuaded on the balance of probabilities that the absence of rational motivation is evidence of a total absence of the capacity for control.

1. Intoxication
   
   The issue of voluntary intoxication has been raised with respect to the serious assaults on police officers on 30 September 2002.  The only evidence of this is the defendant’s self report to Dr Leong.  He is an unreliable historian.  There is no collateral evidence of intoxication in the police material.  I am not satisfied on the balance of probabilities that he was voluntarily intoxicated with amphetamines on that occasion. 

1. 15 October 2002

It was common ground at the Bar table that the defendant was not of unsound mind at the time of his failure to appear on 15 October 2002.

1. Not of unsound mind

Accordingly I find the defendant was not of unsound mind with respect to any of the offences with which he was been charged.

1. Present condition

The defendant is still on a forensic order as a result of the Mental Health Tribunal’s finding he was of unsound mind in relation to earlier charges.  He is an inpatient in The Park High Security Program Authorised Mental Health Service. 

1. The clinical difficulties in managing the defendant’s illness were graphically described by Dr Varghese as follows –

“With respect to question of his future clinical management and where and how this should occur it would seem to me that this is the single most important clinical issue currently.  Whatever the precise legal answers to the questions of unsoundness of mind and fitness for trial, at a clinical level what we are faced with is a young man with very poor social supports, a history of antisocial behaviour, including violence and substance abuse and who also has a serious mental illness, namely chronic paranoid schizophrenia.  Given his past behaviour he would have to be considered to be a seriously dangerous patient and while there may well be antisocial aspects in his premorbid personality, in my view the dangerousness stems from his schizophrenia.  He has engaged in a succession of assaults in both institutional settings and while in the community and it is only a matter of time before someone is very seriously injured or worse.  

If he receives a term of imprisonment, unless he can be legally compelled to take medication which is doubtful, it can be predicted with certainty that he will relapse into acute psychosis requiring transfer to a secure psychiatric hospital.  We are then likely to see a repeat of what has happened before which is a revolving cycle between prison, secure hospital, non secure hospital and community treatment.

In my opinion unless there is substantial change in his clinical condition as a result of treatment it will not be possible or safe to manage [the defendant] within mainstream psychiatric services involving a general hospital inpatient unit and in generic community mental health.  Lack of adherence to treatment and abuse of substances is likely to result in re-emergence of psychosis with resultant dangerous behaviour involving risk to staff, fellow patients or members of the community and moreover this would be entirely foreseeable. 

In my opinion he should remain in a medium secure unit as at present with transfer to secure unit if his condition deteriorates and with eventual transfer to a less secure extended care rehabilitation unit if his condition improves.

I believe [the defendant] should remain in an extended care facility for a prolonged period so as to ensure that he receives appropriate treatment and is not at risk of substance abuse. Such a procedure would allow a prolonged trial of antipsychotics and perhaps even of Clozapine in order to achieve maximum response.  I believe [the defendant] needs a prolonged period of being relatively non-psychotic before community treatment or mainstream care can be considered. [the defendant] presents an enormous challenge in the treatment of the mentally abnormal offender who is dangerous.  It is likely that every service that is made responsible for his care will wish to see that some other sector is responsible.”

(Report 21 April 2004). 

“With respect to the question of future management, I do not have any further advice.  I believe [the defendant] requires to be in a high security unit at the present time with gradual transfer to a medium security unit if his condition improves.  I believe moreover that he should be in an extended care facility for a considerable period of time before being transferred to generic mental health services.  I note with concern the lack of response to treatment with a combination of standard anti-psychotics and atypical anti-psychotics.  I note reference in the clinical notes to probable use of Clozapine.  I would support the use of Clozapine in [the defendant] despite the potential dangers of this drug and the fact that [the defendant] is unlikely to be able to give meaningful consent.” 

(Report 6 July 2004).

1. Unfit for trial

I am satisfied that the defendant is presently unfit for trial.  There was no challenge to such a finding.  A further forensic order must follow. 

1. Forensic order

I order that the defendant be detained as a forensic patient in The Park High Security Program Authorised Mental Health Service for involuntary treatment and care.

1. Limited community treatment

In the interests of his rehabilitation, I approve limited community treatment in the nature of escorted leave (on and off the grounds of The Park – Centre for Mental Health), at the discretion of the authorised psychiatrist, on the following conditions:

1.      that he remain under the escort of a health service staff member or members nominated by the authorised psychiatrist for the duration of the limited community treatment; and

2.      that for the purposes of the limited community treatment, he comply with the directions of the nominated staff member or members for its duration.