Not guilty by reason of insanity

2 May 2022

Dr Bryan Betty, College Medical Director
Dr Peter Moodie, College Clinical Advisor 

The Coroner’s office has now released the findings on the deaths of five people who were killed in 2015 and 2016 by patients who were in a florid psychotic state. Four of the patients were found not guilty by reason of insanity.  

While it seems a long time ago that these tragic events occurred, the detailed investigations (each over 100 pages) by the coroner are impressive and make a series of astute observations and sensible recommendations which have implications for specialist general practitioners. In at least two of the cases there were significant interactions with general practitioners and some of the observations and recommendations relate to general practitioners.  I want to focus on those two cases.

The scenarios will be familiar to any general practitioner who has found themselves confronted by a psychotic patient and the subsequent dealings with mental health services. 

Case one 

Patient G was known to both the mental health services and the general practitioner who had treated the patient for over two years. She had a history of manipulative and aggressive behaviour. In 2015, her parents brought her to see her general practitioner and she was in a distressed and paranoid state.  She was plainly psychotic and at one point had attempted to assault the GP.  The GP arranged for an acute admission via the emergency department (ED) as the duty psychiatrist had gone home (this was at 3.30pm on a Friday).  In addition to a phone call the GP also faxed through a referral letter (which was subsequently lost by the hospital); however, the fax transmission details were logged, which was proof it was sent.  The patient was seen in ED by the acute assessment team (a social worker and a nurse). The GPs letter was not read by the assessment team, who then deemed that she was fit for discharge. Later that day the patient stabbed and killed a family member and wounded four others.

In addition to interviewing the interested parties, the coroner also reviewed some 3,600 pages of clinical records. The patient’s history showed her constantly trying to negotiate a lowering of the dose of her medication along with periods of non-adherence to medication and other treatment options. 

On the day of her acute presentation to the ED, the coroner identified that crucial elements of her history were unavailable to the CATT team, as was apparently, the referral letter from the general practitioner (although there were observations made that had very likely come from that letter).  

Although the assessment was done with Patient G’s parents present, they were not interviewed separately. This meant that the parents did not have the opportunity to discuss their concerns openly with the CATT team. The patient was quite guarded in her responses, saying things like, “she had had a bad day and felt OK now.”

The coroner concluded that had the CATT team known the full story, she would have been placed under a compulsory order as she was plainly at risk of harming herself and others. That this did not happen was partly because the CATT team did not see the GPs referral letter (which the coroner suggested should have been sent electronically).  Further, the coroner recommended the general practitioner should have been contacted as he had intimate knowledge of the patient and her behaviour.

The coroner made a very insightful statement noting, “The importance of a general practitioner’s day-to-day knowledge of a patient can in my view be underestimated.”

Case two 

The patient lived with his parents and had a history of psychotic and paranoid ideation. He was known to the psychiatric services although he had on occasions been referred back to his general practitioner. His family, a neighbour, an art teacher, and an employment consultant had all observed and reported examples of florid psychotic behaviour. On at least one occasion the patient had threatened his parents with a length of wood and then a baseball bat. On another occasion a neighbour who knew him well realised that he was in her house with three knives that he was trying to conceal. 

The baseball bat incident resulted in him being taken to ED by the police and assessed by the CATT team; he was however deemed fit to return home.

When the patient encountered health professionals, he was focused on having his medication dosage reduced and insisting that his parents not be included in his management. Although members of the public could easily identify that he was seriously unwell, in the presence of health professionals he could behave in a rational way.

Shortly before he murdered his mother, the patient was seen by his GP at the request of the employment consultant who was concerned about his behaviour.  At the interview with the general practitioner the patient behaved rationally; however, after the appointment, the doctor then spoke to the employment consultant. Following that, the GP contacted what she critically thought was the CATT team (it was in fact the phone triage centre, Te Haika). She was told that as the patient had been assessed by a mental health team some days before there was little to do until the patient became overtly aggressive. 

A psychiatrist from the DHB told the coroner:

“Can I say, the other part of learning that I have been thinking about is how do we equip GPs to be more assertive and, you know, if a GP is concerned and worried and Dr B and (doctors) in our previous inquest and have good knowledge and they know things aren't right, why didn't they commence the Mental Health Act themselves which would have forced, again may not have changed the outcome but it may have, there may have been a different assessment given if someone had completed, you know, the first part of the Act requesting the section 10 assessment and so I wonder about that, about, yes, the certainness of GPs and their seeming, I don't know if this is the right word but almost like helpless response in the face of being turned down by the mental health service rather than coming back again and saying, “I really believe you've got this wrong. I want to speak to a consultant now.” So that part of what, you know, as the primary care kind of team, how do they help advocate that when they see the quite clear signs. So how do we help the GPs be more assertive in the system of care.”

Unfortunately, a short time later the patient did become aggressive and stabbed his mother to death and attacked another family member with a hammer.

Conclusions

These cases make for distressing reading and are complex with systemic failures at the heart of the problem. Often there are multiple health workers involved. Fragmentation in care often leads to  barriers to good care.

These types of cases are monumentally complicated with conflicting forces occurring, including:

  • A family at their wits end but feeling guilty, coping both with the patient and system and feeling excluded. 
  • A number of people holding pieces of information but without the ability to pull them all together. 
  • DHB staff who are acting as gate keepers.
  • Patients who are resistant to treatment, through lack of insight or because they have had bad experiences with institutional care and the system.

For vulnerable patients and their families their most valuable asset is a long-term relationship with a trusted practitioner – more often than not the general practitioner. This can never be replaced by episodic acute management by multiple agencies.  

The general practitioner in these situations should have ready access to their mental health peers and mental health information. To be clear, this means that they have the absolute right to discuss a difficult case with a consultant psychiatrist and formulate a plan which can be implemented.  

Responsibility for the overall clinical care needs to come from the top, not from the bottom.  In this way we will truly be giving compassionate and efficient care to patients.

What are the learnings?

  • When you are concerned about a patient and refer them, be ASSERTIVE. Say what you think and if it is a phone call, identify exactly who you are talking to. 
  • Insist on talking to a consultant psychiatrist if you have concerns.  
  • If you have an expectation about the type of care required, you need to state it clearly. You should also state that if your recommendation is not to be acted upon, then you should be contacted (leave your contact number) and you may wish to speak to a more senior member of the mental health team.
    • These cases are monumentally complicated, and a peer-to-peer discussion is the safest form of communication. You may well be the person who has the greatest insight into the case.
  • Once you have made a referral, document it carefully.
    • If something goes wrong, you may find that other health professionals have a very different interpretation of what you said/documented.
  • Keep clinical antennae up with patients who are guarded in their communication. Despite being psychotic, some patients can be wary of health professionals who may insist on treatments that they find intolerable.
  • When family members or indeed other members of the public report abnormal behaviour you need to talk to and listen to them. This is not breaking patient confidentiality and may be critical to everyone’s welfare. You need to interview these people often without the patient present.
  • We have a duty of care to our patients and their families and better outcomes for both should be paramount in our thinking.
  • Reread and assess what the DHB psychiatrist said:

“Can I say, the other part of learning that I have been thinking about is how do we equip GPs to be more assertive and, you know, if a GP is concerned and worried and Dr B and (doctors) in our previous inquest and have good knowledge and they know things aren't right, why didn't they commence the Mental Health Act themselves which would have forced, again may not have changed the outcome but it may have, there may have been a different assessment given if someone had completed, you know, the first part of the Act requesting the section 10 assessment and so I wonder about that, about, yes, the certainness of GPs and their seeming, I don't know if this is the right word but almost like helpless response in the face of being turned down by the mental health service rather than coming back again and saying, “I really believe you've got this wrong. I want to speak to a consultant now.” So that part of what, you know, as the primary care kind of team, how do they help advocate that when they see the quite clear signs. So how do we help the GPs be more assertive in the system of care.”

Comments from the College’s Quality team

The Foundation Standard requires general practices in New Zealand to comply with the National Adverse Events Reporting Policy, whereby practices can reduce risks and improve patient safety by analysing information and focusing on their processes and systems.  The issues in case one are not only the failure of the GP referral to reach the CATT team at ED, but also the systemic weaknesses which aligned to result in a serious event (the Swiss cheese effect). Indicator 13: Health and safety - 13.3 Incident management.

Both case one and two involved clinical correspondence; in case one the referral was lost and in case two, the GP was unable to lodge an effective referral to the CATT team.  The Foundation Standards clinical correspondence management, indicator 5, helps practices formulate strong processes on the management of clinical correspondence, including urgent referrals and safety netting. Having a documented clinical correspondence and investigations policy and procedure, ensures all team members are consistent in that way these are managed and tracked. Indicator 5: Continuity of care -5.1 – clinical correspondence

Incident management/patient safety and clinical effectiveness are included in the clinical governance framework which practices have been adopting since the Foundation Standards launch in 2020. Indicator 8: Clinical governance and patient experiences - 8.2 Elements of clinical governance.

The scenarios seen in both these cases would initiate a significant event, reportable to and followed up by the clinical governance group, a forum where important practice issues are holistically managed. The group has patient safety and wellbeing, quality of care and services as a primary focus and can initiate change in practice policy, process, and systems.

General practices must comply with New Zealand’s laws and regulations. The Foundation Standard makes this achievable by combining all requirements in one place. Three yearly Foundation Standard assessment and recertification provides assurance to practices and their patients that they remain compliant and are delivering safe and effective healthcare.