Anthony Maden MD, MRCPsychProfessor of Forensic Psychiatry

AcademicCentre

Tel:Fax:

04 February2005

Supplementary Psychiatric Report on Robert Stewart (dob 4.8.1980)forthe Zahid Mubarek Inquiry

Introduction

I am preparingthis reportatthe requestof The Treasury Solicitor,actingon behalfof thePrisonService. It isto be read in conjunctionwith my firstreport,dated 17.12.2004.Sincepreparingthat report, I have seen a copy of ProfessorGunn'sreport andI havebeenasked to commenton it. I have also beenaskedto comment in moredetailonStewart'smanagementwithinprisonand, in particular,to comment on hismedicalmanagement. I have metwith ProfessorGunnandwe discussedthe case for abouthalfan houron 2ndFebruary 2005.

The Writer of the ReportDetailsare giveninthe firstreport.

Duty to the Court

I understandthatmy overridingdutyis to assistthe court on matterswhichare withinmyexpertise. I alsounderstandthat thisduty oven'idesany obligationto thoseinstructingme.

LayoutI beginbysummarisingsomeentriesinthe records,includingmedical, disciplineandprobationrecords.I go on to give commentson theserecordsandon ProfessorGunn'sreport.

Information from Records.

6.10.97. IMR "Seen at request of wing staff, concerned his behaviour may be drugrelated. Was taking amitryptiline, dihydrocodeine, diazepam 3-4 times weekly outside,mixed with alcohol daily. Was taking mushrooms for the fortnight before beingremanded. Short term memory loss. Says he feels odd compulsive actions. Unsure if hehears voices telling him to do it, can't explain his actions. Says he was like this when last

-2090-

in W..... House. Was seen by a psychiatrist at Booth Hall when aged 10, no recentpsychiatric involvement. Says he isn't depressed in mood. Denies any drug use in here."Signed by Nurse/Drug Worker

7.10.97(? date unclear) IMR Spoke with Stewart about impulsive actions whilst denyinghearing voices. Feels he must carry out whatever actions he feels to do. This tends tohappen during quiet periods. No bizarre behaviour noted during time spent on HCC butmood is fiat.

10.10.97 (date unclear) IMR "Feels ok. Has no plans of self-harm. Says it came to himto harm. No voices heard. No hallucinations. All these things happen when in prison.Review tomorrow. Sleeps _-++. Try fluoxetine."

11.10.97 IMR "No abnormality observed. May be transferred to ordinary location"

11.10.97. IMR ''Nursing Notes. Approx 1300 h Stewart began to flood his cell out tocause damage to lino and lockers. Has not displayed any stranger behaviour in the 6 dayshas been on HCC. It would appear he did this hoping to stay on HCC. Removed to SegUnit by .... discipline staff."

26.10.97 IMR Nursing Notes. Called to Seg Unit. Inmate had flooded cell, smearedfaeces on the walls and covered himself in butter. Removed by staffto Sp/Cell 1. Noinjuries or complaints. Stated he "did it for a laugh". Possible connection that Travis isalso in Seg Unit. Contacted Dr. Greenwood and advised him of situation. Agreed to leavehim in his present location overnight if duty governor agrees.

27.10.97. IMR. Fit for adjudication.

22.11.97. Security Information Report. Travis and Stewart "are a danger to themselvesas they are inciting each other to harm themselves. I believe they will go to great lengthsto be kept together and could endanger their lives and possibly others. I believe theymanipulate the system to their own ends and [are] quite determined to get their ownway".

22.11.97. IMR 0600h "settled. For possible return to O/L [ordinary location] after seeingMO". 1130h "Seen by MO. Happy to return to F wing." 1700h "Inmate tried to set fire tohimself in his cell. He offers no explanation for his behaviour. We cannot get through tohim at all. Located in the HCC." lit is not absolutely clear from the record but the senseof these entries is that the incident occurred when he had been moved back to ordinarylocation, and resulted in his return to the Health Care Centre]. 1930h Admitted to HCCfrom F wing. Immediately after admission Stewart was chatting and laughing downlanding with other inmates, bragging about his behaviour and asking Travis to get himselfput into H 1-02"

23.11.97 IMR 0600h "Discussing with I and Travis various ways to s/harm". 1030h"Seen by Dr. Das, behaviour is all an act in order to be in the HCC next to Travis.Stewart is also inciting Travis to harm himself in order to be located in cell...next to him.For O/L or seg. Unit".

24.11.97 [? Error in date] IMR "Located on G wing at 11.05"

23.11.97 IMR 200Oh. "Stewart just sat on bed".2310h. "Called to Seg. Stewart had tiedstrips of shirt around his neck, wrists and legs." He was placed in a strip cell and to see

-2091-

MO the next day. 2335h "..banging his head on the wall...then sat down in thecomer.., started to bite his arm.. [illegible]... informed hospital".

23.11.97 IMR Seen in Seg in strip cell. Tried to hang himself. Does not know why he ishere. Says does not want to harm himself. No suicidal intent.

24.11.97 IMR 1600h "Transferred to HCC Lancaster Farms for observation...

24.11.97. IMR Received at Lancaster Farms. "boy with self-harm problems".

25.11.97 IMR 1145h "No signs of low mood or self-harm behaviour. In good humour,wants to go to normal location. Says only got to hospital wing to be with his fi,iend".

28.11.97 IMR A psychiatric history and assessment is recorded over a page and a half. Itwas partly illegible on my copy. Notes he is serving four months and due for sentence on31.12.97 on a charge of assault. There is a note of his home situation and a family historyof psychiatric disorder in his mother and criminality in his brother. There is aneducational history, a history of being in care, and a detailed drug and alcohol history.There is a description of contact with psychiatric services and of deliberate self-harm,along with an account of his stated motivation for recent attempts at self-harm withinprison (he wanted to be in hospital rather than seg uni0. His mental state is recordedbriefly as "relaxed, not depressed, no ideas of self harm [plus one illegible line]". Adecision was made to consider for transfer to ordinary location, as well as refer to"counsellors".

2.12.97. Discharge Report For release on license on 31.12.97. Likely to re-offend, doesnot think ahead. "A very disturbed and, in my opinion, dangerous young man".

13.12.97. Cat E Review Board. Personal Officer's Recommendations "A very strangeyoung man. I have tried on numerous occasions to get through to him but to no avail.Although he has caused no problems on the wing I feel he does suffer from some sort ofpsychological illness".

27.12.97 IM]R. Record of eating soap and disinfectant in Hindley, 11.10.97 - "says as hewanted to be in hospital". Bite to wrist and superficial cuts to arm. Later, flooded cell.Staff "questioned him and thought he was "spaced out" and talking gibberish". Appearedlucid and coherent when seen.

23.6.98. Discipline file. Involved with Travis in stabbing and killing another inmate."...although Stewart did not do it, he was involved with other inmates who were planningto take the cookery teacher hostage and "carve him up". Stewart may come across as aweakling but he is an extremely dangerous individual and all wing staff should read hissecurity file. He was big buddies with the murderer."

23.6.98 Security Information Stewart and Travis said to have planned to take whole of• home economics class hostage, in order_o escape. "Travis and Stewart are big buddies

and ....... told me that it is very likely that Stewart would do anything of a serious natureto follow Travis wherever he goes."

Stewart was place on R46, GOAD.

25.6.98 IMR. The first reference in medical records relating to the killing.

-2092-

20.9.98 Discipline file. "..had ripped his mattress in two and scattered the bits around hiscell, states just messing about, placed on Governor's report, very quiet, declinedbreakfast."

7.10.98 First Stage Assessment of Risk of Harm Thought to be high risk of harrn,triggered by arrest, motivated by excitement. Other inmates and prison officersmentioned as possible victim categories.

12.10.98 Pre-Sentence Report by Probation Officer. Concerning arson with intent toendanger life, on 10.8.98. Had been locked up with Travis who was also involved but notcharged. "...portrayed the setting alight of bedding, etc almost as an act of fun". Alertedstaff when fire seemed to be getting out of control. "'Withhindsight he could see the riskthis behaviour posed to himself and his cell mate. But I did not feel he could see thewider implications of the fire affecting other inmates or staff who may well have been putdirectly at risk by behaviour that had no purpose or intent beyond possibly alleviatingboredom". Goes on to note recidivist offending and "...lifestyle that at one level heappears content with...". "The one stable feature appears to be the family home. Hisparents have always supported him...and will I anticipate continue to do so". The reportgoes on to discuss: "Risk to the Public of Re-Offending. Although confined within a cellthe potential for harm to others was significant and as previously stated the intent seemsto be not against any individual or the institution but involves and element of fun thatperhaps reflects an immaturity that cannot see the consequences of behaviour. Suchattitudes are apparent in all his offending and therefore at this level the arson charge is nodifferent from other offending. This suggests that the risk of re-offending and the risk ofharm remain significant."

He was sentenced to 12 months for the arson.

24.10.98 Discipline File. Has pleaded guilty to use of threatening words or behaviour."Cannot be trusted for even a minute. He is very hard to have a conversation withalthough in my opinion he is usually polite to staff."

15.12.98 Discipline File "No problem so far whilst located on the Seg unit".

22.12.98. Discipline File "The bully has raised his head once more. Named as bully byanother inmate. This lad is a disaster waiting to happen. I have known him for someconsiderable time at Hindley. He is consistently a threat to the security of theestablishment."

23.12.98 ACR 1 Notes he finds some of his violence amusing, shows no concern forothers, no remorse.

10.1.99. Discipline File. Threw evening meal over wall - "...just felt like doing it".

12.1.99. Discipline File. "..assaulted another inmate by stabbing him below the eye witha sharp piece of wood".

13.1.99 IMR." Seen in G wing after swallowing part of a small battery ..... States he didit for a laugh".

24.1.99. Inmate Intelligence Card. Letter states "...if he gets his L Plates he will go sickand take hostages".

-2093-

19.2.99 HDC 1 Unsuitable for Home Detention Curfew because of his record. He isassessed as high risk of violent offending and re-imprisonment

23.3.99. Personal Officer's report to HDC1. "...causing no problems but...disasterwaiting to happen .... doesn't communicate well with staff or other inmates. Has to beclosely supervised at all times".

23.5.99. Discipline Record. "Things have improved. He is certainly not a candidate forbasic at present."

6.6.99. Discipline Record "The improvement in this young man's attitude and behaviouris quite remarkable. He has only four weeks left and in my opinion deserves somerecognition for the way he has turned himself around".

9.6.99 Discipline Record. Placed on enhanced regime because of"vast improvement" inbehaviour.

28.6.99 Personal Officer comment on Sentence Plan Review ACR2. "..has made a bigimprovement with attitude and behaviour while on F Wing and works well on education".

8.7.99. First Stage Assessment of Risk of Harm. Other inmates are not mentioned aspotential victims. He is now considered only medium risk. RM2 completed.

16.11.99 IMR Assessed by CPN at Altcourse after Unit Manager requested psychiatricassessment. Diagnosed as untreatable personality disorder.

10.1.2000. Pre-Sentence Probation Report Charged with dangerous driving and vehicleinsurance offences. Based on a telephone interview but the officer had prior knowledgefrom supervision. "..little insight...little understanding of the negative consequences ofhis behaviour for himself or others". "When challenged regarding his behaviour, thedefendant's usual response would be to giggle, a fact which perhaps reflects the level ofhis immaturity". "..often under the influence of drugs or alcohol during the commissionof his offences. He has shown little motivation to address this problem." "..susceptibilityto peer influence and impulsive behaviour is demonstrated in a recent offence of arson."Only out of custody for two weeks, suggesting "...a continuing pattern of impulsive andoffence related behaviour whilst in the company of peers". "..lack of motivation tochange...high risk of him reoffending...potential to become involved in a wide range ofoffences". There is a discussion of risk to the public, focussing mainly on other roadusers and pedestrians but mentioning two convictions for assault and one for arson,indicating a "potential for dangerous and threatening behaviour in certain situations. Iunderstand that both assaults were committed when the defendant was challenged duringthe commission of motor vehicle theft."

Opinion

1. Medicaland Other Records:Diagnosis.

1.1 On the face of it, Stewartappearsto showhighlydisturbedbehaviourinlate1997 andearly 1998, includingfiresettingandself-harm,suggestiveof mentalillness.In fact, thenotesshowthatthe mostlikelyexplanationisthat hisbehaviourwas manipulativeanddesignedto get hisownway, in thecontextof

-2094-

an abnormalpersonality.He wantedto be locatedwith his friend, Travis,and wasprepared to go to extreme lengths to achieve this end. He was also impulsiveand capable of behaving recklesslyand dangerously out of boredom or a needfor stimulation (the phrase "for a laugh" recurs several times).

1.2 In psychiatric terms the crucial decision was between two broad diagnoses:mental illness and personality disorder.

1.3 This decision had profound implications, as a diagnosis of mental illness wouldhave sent the case off on different track, where management would have beendictated primarily by medical considerations. The team looking after him decidedthat he was suffering from personality disorder, and he went down a differenttrack, where medical considerations were much less important.

1.4 One can never be absolutely certain about any diagnosis in psychiatry but apersonality disorder is still, even with all the benefit of hindsight, more likely thanthe possibility that he was mentally ill. It is also the diagnosis reached by Drs.Joseph and Nayani and, not having seen Stewart, I am in no position to disagreewith it, nor would I wish to do so. I base my comments on the assumptionthat hesuffered from a personality disorder.

1.5 I would respectfully recommend to the Inquiry that one has to take a position onthe question of diagnosis. This issue cannot be avoided or fudged. If the healthcare team missed a case of psychosisor sedous mental illness, they would beopen to many sedous criticisms, including those in Professor Gunn's report. If, onthe other hand, they got the diagnosis right, their position is much stronger.

1.6 Health Care staff did not have the vast time, matedal and documentaryresources available to Drs. Joseph and Nayani, nor did they have the benefit ofhindsight, so they deserve credit for reaching (essentially) the same diagnosis.

2. MedicalandOther Records:Managementof a Case of Severe PersonalityDisorder.

2.1 There was a seriousdilemmafor staffinHealthCare. One of theirmainfunctionsis to preventself-harmandsuicide.Stewart(and Travis)recognisedthispriorityandabusedand exploitedthecaringand concernof stafffor theirown,rather

trivial, purposes- sometimes,"fora laugh'.There is no signof any remorseorrecognitionthatwhattheywere doingwas wrong.

2.2 Stewart'sbehaviouron severaloccasionswas analogousto makingbogus999calls. HealthCare Staff haveto respond,for fear thatthere may be a genuineriskof suicide,yettheyknowafterwardsthat theyhave beenwastingtheirtime.Thesystemis undergreattimepressureand,whilstHealthCare staffdealtwithStewart, theywere notdealing withthose inmateswho were at genuinelyhighriskof suicide.

2.3 I have nosubstantialcriticismto make of theway in which HCC staffmanagedtheseincidents.In particular,I do notbelievethat theywere ever negligent.Theydidnotrejectthecase butre-assessedon numerousoccasions,alwaysreconsideringthe crucialquestionsofwhethertheywere missingmentalillness(depressionor psychosis),orwhethertherewas a highriskof self harm.

2.4 Someentriesinthe recordscould have been moretactfullyworded.On theotherhand,staffthroughouttheNHS commonlyexpressangerand frustrationwhen

-2095-

dealing with patients who manipulate them. These feelings should never becommunicated to the patient and they should not find their way into the records,but sometimes they do. The price of having caring staff is that they get upsetwhen their desire to help is exploited.

2.5 It can be argued that a psychiatrist should have bccn asked to see Stewart,particularly after the incident on 26.10.97. In my opinion, that would have beenthe ideal management of the case. Instead, he was assessed by a member ofhealth care staff who discussed the case with Dr. Greenwood. I believe this was

within the range of acceptable actions, in a difficultsituation. In fact, HCC staffchose not to use the psychiatrist (a scarce resource in this setting) and they didthe right thing anyway. To pursue the analogy above, calling out the psychiatristwould have been like sending an extra fire engine in response to the bogus 999call. It would have been a safer response but, in the event of a false alarm, itwould have been a greater waste of resources.

3. Comments on Professor Gun.n'sReport

3.1 There is a lot of common ground but I will concentrate here on the differencesbetween us. I have indicated the relevant paragraphs in Prof Gunn's report whenpossible.

3.2 Para 25. The major difference between us is probably over the issue ofdiagnosis. As stated above, one has to choose between two alternatives. If thiswere a case of mental illness, I would agree with many of Prof Gunn'scomments. I find the use of the term =mental disturbance" confusing. Both mentalillness and personality disorder are forms of mental disorder and severepersonality disorder implies severe mental disturbance, but it is still not to beconfused with the mental disturbance in mental illness.

3.3 Para 10. The other major disagreement is over psychopathy and the work ofRobert Hare. Hate's development of the PCL-R scale (and the shorter PCL-SV)is the most important development in the study of personality disorder in the lastfd_yyears. It has transformed the scientific study of antisocial or dissocialpersonality disorder and has led to the resurrection of the term psychopathy.

3.4 Prof Gunn is correct in saying that psychopathy was an outmoded andambiguous term. Hare made it useful again by creating a valid and reliablemeasure of psychopathy. For the first time, it was possible for clinicians andresearchers to agree on a measure, and to be confident that they were all talkingabout the same thing. In many ways, it is unfortunate that Hare chose to use theterm psychopathy for his scale, because is has so many undesirableconnotations, but these considerations should not detract from the value of hiswork. The first step in any scientific endeavour is measurement, and the PCL-Rhas allowed a massive expansion in the scientific literature on personalitydisorder.

3.5 The other important quality of the PCL-R is its ability to discriminate betweenoffenders on the basis of personality characteristics. As stated in my first report,the definition of ASPD or dissocial PD is contaminated by criminality, so mostrecidivist offenders will get that diagnosis. In prison populations, where recidivistoffending is the norm, ASPD or dissocial PD is also the norm, so the term is

-2096-

almostuseless.By contrast,psychopathyas definedon the PCL-R isfoundinonlyaboutone inten longtermprisoners.

3.6 WhilstHare himselfhas personal idiosyncrasies,hisChecklistcannotbedismissedas oneof them. There are thousandsof publishedpapersusingthistool(see www.hare.orgfor a list).The PCL-R isthe maintoolfor themeasurementof antisocialpersonalitydisorderthroughoutCanadaandthe USA.It is a majorpartof assessmentn the DutchTBS system.It is at the heartof riskmanagementand offendingbehaviourprogrammesin the EnglishandScottishprisonsystems,and it forms the basisfor the DangerousandSevere PersonalityDisorder(DSPD) serviceinthiscountry.The PCL-SV is usedas a screeningtoolbythe Reasideclinicandby forensicpersonalitydisorderservicesat theSouthLondonandMaudsleyNHS Trust,wherebothProfGunn andI workedformanyyears. Inthe largesteverstudyof violencebypsychiatricpatientsafterdischargefrom hospital,the Mac,Arthurstudyinthe USA, the PCL-SV emergedas thebestsingleindicatorof violencerisk.

3.7 I agreewithProf Gunnthat psychologistsare morelikelythan psychiatriststousethe termpsychopath.Hare is a psychologistandthe PCL is morewidelyused by psychologiststhan by psychiatrists.Furthermore,manyof thosewhousethe PCL-R are forensicratherthanclinicalpsychologists.Psychopathyandthe PCL-R are usefulin forensicmentalhealthservicesbut theywere notdevelopedwithina healthframeworkandtheirmainapplicationhasbeen inprisonandcriminaljusticesettings.I have a particularinterestin thisfieldand Ihave soughtout traininginpsychopathyandthe PCL. Psychopathyandthe PCL-R are nowpartof a comprehensivetraininginforensicpsychiatry.I trainabout120 healthcare personnelper annum,aboutone thirdof them psychiatrists,inuse of thePCL-SV. The course is alwaysoversubscribed.

3.8 On theotherhand,ProfessorGunn'sattitudetowardsHate's work is commonamongseniorforensicpsychiatristsin England,and it maywellrepresentamajorityviewamongthoseof uswho trainedbefore Hate'sworkbecamewidelyknown.This is a new developmentinthe UK andit is importantfor the Inquirytohavethat inmindwhenjudgingStewart'sassessmentand management.

3.9 Para 28. The judgmentabout the appropriatelevel of medicalinterestdependspartlyon thediagnosis.I wouldagree with ProfGunn ifthiswere a case ofmentalillnessbut it is a case of personalitydisorder.Considerationsof thecorrectassessmentand managementof psychopathyare thereforemorerelevantandthe expectationsof doctorsare muchless.

3.10 Stewart hadnumerousmental healthassessmentsbuthewas notassessedbyapsychiatrist.One'sjudgmentof thequalityof the mentalhealthassessmentsisboundto be formedby whetheror nottheygot thediagnosisright,as I believetheydid.

3.11 What wouldan assessmentby a psychiatristhave added?In myopinion,psychiatricassessmenthadtwofunctions:first,exclusionof treatablementalillnesssuchas schizophreniaor depression;and, second,betterassessmentandmanagementof the personalitydisorderand its associatedrisk. I shalldealwiththesetasksseparately.

3.12 HealthCare carriedoutthe firsttaskeffectivelyand checkedrepeatedlyfortreatablementalillness.The doctorsandotherstaffwho sawStewart lookedfor

-2097-

additionalsymptomsof mentalillness(hearingvoices,depression,etc)anddidnotfindthem. Theyasked alsoaboutmotivation,andthey lookedcarefullyat thecontextandStewart'srelationshipsandotherbehaviour.Theyconcludedthat thebehaviourswere probablyattemptsto manipulatethe systemand to relieveboredom,in an impulsiveyoungmanwitha severepersonalitydisorder.Asnotedabovetheywere right,at least inso far as theirconclusionswereconfirmedby Drs. Josephand Nayaniafterthe killing.A psychiatristwouldhavegone throughsimilarstepsandwouldprobablyhave reached thesameconclusions.There is no reasonto supposethat a psychiatristwouldhave donethe job better.The keyto thecorrectdiagnosisinthiscase is observationanddetailedknowledge of Stewart,hisrelationshipsandhisenvironment.

3.13 Turningnowto thesecond task,it is mostunlikelythat a psychiatristwouldhavehadthe knowledgeandexpertiseinassessingpsychopathy,to providebetterassessmentof the personalitydisorderandthe associatedrisk.The key to thiscase is use ofthe PCL-Rto measurethe levelof psychopathy,but psychiatrists(as exemplifiedby ProfGunnand by Drs Josephand Nayani)do not usethisinstrument.It isthereforeunlikelythata psychiatricassessmentwouldhaveaddedanythingto an understandingof hispersonalitydisorderandtheassociatedrisk of violence.

3.14 Para 35 1wouldbe astonishedifa psychiatricassessmenthadproducedanythingbetterthan the assessmentbythe CPN in November1999. Inthecontextof Britishmentalhealthservices,where there is virtuallyno traininginthestandardisedassessmentof personalitydisorder,that was a reasonableassessment.The CPN's judgment was inlinewiththe findingsof JosephandNayani.One mustalsoappreciatethe predicamentof staffon the ground,whohaveto take these difficultdecisionswithfar lesstime and resourcesthan wereavailableto Josephand Nayani.A case couldhave beenmade for theCPN toreferStewart to the psychiatristbut modemteam workinggivesconsiderableresponsibilityto CPNs and I do notbelievehe exceeded that responsibility.Also,I do notacceptthat Stewartwas ever rejectedby NHS or healthservices.Hewasassessedrepeatedlyfor self harmriskandmentalillness,despitecryingwolfon more thanone occasion.As thereis no specifictreatmentfor hisunderlyingdisorder,psychopathy,the questionof withholdingitfrom himcannotarise.Again,thiswouldbe verydifferentifhe sufferedfrom schizophreniaor anothermentalillness.

3.15 Para 11. I agree withmanyofthe commentsaboutthe word=untreatable"and itisan unsatisfactorytermthat is usedto mean incurable.However,the termsarenOtsynonymous.Many psychiatricdiseasesare incurable,but treatmentproducesobviousandrapidimprovement.That is notthe case withpsychopathy.Thecurrentstateof knowledgeisthat treatmentdoesnotproduceapparentbenefit.Such improvementas may occurinpsychopathy(a reductioninthe riskof offending)willprobablybe achievedthroughOffendingBehaviourProgrammes(OBPs),whichare notusuallypartof medicaltreatment.

3.16 Para t 3. I wouldalso liketo see moreresourcesforhealthbut the ONS figureson the prevalenceof PD inprisoners(in myfirstreport) showthat thisis notthecompleteanswer.The healthservicewillnever be able to treat all prisonerswithpersonalitydisorderand therewillalwaysbe an issueof where to drawthe line.There is alsoa real issueof therapeuticbenefit(see precedingparagraph)and aqueuefor treatmentonlybecomesrelevantwhen effectivetreatmentis available.

-2098-

3.17 Para 37 1do notbelievethat psychiatricassessmentat thispointwouldhavemateriallyalteredmanagementor outcome.There was no crisisand certainlynoindicationfor continuouswatch.Therewas nothingnew about the diagnosis,whichwas implicitinpreviousrecords,andStewartwas nowbetter knowntohealthcare (at leastthroughrecords).It is onlywithhindsightthat one couldrecommendthiscourseof action.Therewas a laterriskassessmentbyprobation,whichI discussbelow.

3.18 Para 38 1agree that personalofficersare a goodthingbut havequoted someoftheircommentsinthiscase. They fared no better thananyoneelse in gettingcloseto Stewart, and a psychiatristwouldhave hadthe same problem.

3.19 Para 42-44 We agree that theunderlyingmentaldisorderplayeda significantrole,althoughI wouldputthe case morestrongly.There is no directevidenceforthe fluctuatingpsychoticconditionor neurologicalabnormality.The "traditionalpre-releasebeating"is unlikelygiventhe ferocityof the assaultand Stewart'spositionas a loner.We agreethat thequestionof racismgoesbeyondpsychiatricexpertisebut itdoes notseem to have beenimportantto the outcomeandthere is nothingto suggestthat a cell mateof the same ethnicgroupwouldhave been safe.

4. The MedicalRolein RiskAssessmentand Management

4.1 Neither Professor Gunn nor I addressed this question directly, because it wasimplicit in the Inquiry's questions that risk management was largely an issue formedical services. In fact, I believe that the medical role in risk management isoften a limited one, particularly in the absence of mental illness.

4.2 Mental illness is relatively straightforward. Symptoms such as hallucinations anddelusions, as well as extremes of depression or anger, may trump all other riskpredictors. Other risk management may be useless if the symptoms are notcontrolled, and medical intervention can bring both symptoms and risk undercontrol quickly, in a way that no other intervention could achieve.

4.3 Personality disorder is different. There is no established treatment for severepersonality disorder or psychopathy and the new DSPD services are based onworking around the PD rather than treating it. They treat personality disorder as a"treatment interfering factor" and attempt to get round it in some way, to deliverthe offending behaviour programmes that are known to reduce risk in offenderswithout serious PD or psychopathy. Medical input has little to offer. Programmesare usually delivered by psychologists or discipline staff with special training.

4.4 Despite the lack of psychiatric involvement, Stewart had several riskassessments. It is worth considering what they said and what difference a medicalcontribution would have made, if any.

4.5 A risk assessment is documented in the Probation Officer's Pre-Sentenee Reportof 9.10.98, relating to the offence of arson with intent to endanger life. I havequoted at some length from that report but would refer the Inquiry to the originaldocument. It is a good risk assessment. It is better than one could have expectedfrom a psychiatrist.

-2099-

4.6 This risk assessment comes at an important point because it concerns Stewart'smost serious offence before the killing. He pleaded guilty and there was plenty ofinformation about the circumstances of the offence. The only major omission wasthe incident in which he handed a knife to Travis, who then killed another inmate.It is unlikely that incident would have made a big difference to the conclusion.His susceptibility to peer influence was well recognised and this would have beena further example.

4.7 This riskassessmentis in no sense a medicalassessment.Unlessone believesthat Stewartsufferedfroma mentalillness,psychiatryhad littleto addto thatriskassessment.The probationofficermakes no referenceto concernabouthismentalstate.

4.8 The riskassessmentofferedno reassuranceaboutfuturere-offendinganditdrewattentionto thedangersposed to otherinmatesby thearson.It mentionedthe lackof remorse andlackof concern,aswell as the trivialmotivesfortheoffence.Withhindsight,all thesefactorsare relevantto the killing.

4.9 It is importantto notethe court'sresponseto thisreport.So far as I am aware,therewas no requestfor psychiatricreports,eventhoughtheyare commonlyrequestedincases of arson.The courtgave a sentenceof twelvemonthsimprisonment.

4.10 I understandthat the sentenceof a courtcan servea functionof protectingthepublic,in additionto the functionsof retributionanddeterrence.The courtwasmadeaware of the risksinthiscase (as theywere knownat thattime) butdidnotchooseto investigatethe psychiatricaspectsinany moredetail,nordid itchooseto givea sentencewhichwouldhave offeredprotectionto thepublic.

4.11 I do not seek to criticisethecourt'sdecision,and anysuchcriticismwouldfalloutsidemy roleas a psychiatricexpert. However,the courtsare the first lineofprotectionfor thepublicagainstre-offendingbydangerouspeoplewho havejustbeenconvictedof a seriousoffence.I do not believethat it isreasonabletoexpect psychiatricor prisonservicesto do a better job than thecourt. OnceStewartwasgiventhe twelvemonthsentence,hewas consignedto the shortterm prisonsystemwhere medicalinputisoftenlittlemorethan offeringfirstaidor acutecare. I wouldnotexpectshorttermprisonersto have a comprehensiveriskassessmentor managementplan,as wouldhappen inthose servinga longersentence.The outcomeinthiscase may wellhave beendifferenthad Stewartbeengivena considerablylongersentenceand foundhimseffin a partof theprisonservicemoreattunedto the needsof seriousviolentorsexual offenders.

4.12 A further risk assessment is documented in the Probation Officer's Pre-Sentence

Report of 10.1.2000, relating to dangerous driving and vehicle insurance offences.It was carded out by a different probation officer but it is similar to the previousrisk assessment and it is also a good assessment of the risks. Most psychiatristswould not be capable of producing such a good risk assessment because they havenot been trained to do so. Again, there was no indication of the need for medicalreports, which would not have added anything.

4.13 Riskassessmentis nota crystalball and it can neverforetellthe future.Thisassessment,lessthan two monthsbeforethe killing,was of a highstandardandidentifiedmany factorsrelevantto the killing,suchas impulsivity,trivial

-2100-

motivationfor offending,lackof empathyandlack of remorse.Yet, itgave noindicationthathe wouldcommita highlyunusualand extremelyviolentoffenceofthis type.All indicationswere that his violencewouldoccurwhen confrontedincommittinganothercrime,or inrelationto peer influences.A court hadbeenawareof theserisksearlier,whensentencingforarsonwithintent,and hadpresumablyjudgedthat theyfellwithinacceptablelimits.The inevitableconclusionisthat the offencewas notforeseeable.

4.14 The probationomcer hadaccessto informationnotavailableto prisonstaff,and Iwouldexpect his risk assessmentto be better.However,therewereassessmentsdone at varioustimesin prisonand theywere alongsimilarlines.

4.15 The basicproblemis that all risk assessmentsassume(rightly)thatthe past isthe bestguidewe haveto the futurebutthe past is sometimesmisleading.Stewart'spastdidnotsuggesta highriskof an offenceof suchextremeviolenceinthesecircumstances.

4.16 It is importantto acknowledgethe rarityof thistype of offence,essentiallythemotivelesskillingof anotherprisonerwithno hopeof escapingdetection.It isquiteunlikemost killingsof cell mates,whichare rare inany event.Stewarthasjoineda handfulof prisonerswithseverepersonalitydisorderswho have killedotherinmatesforno understandablereason. Ina lay sense,suchpeoplewouldbe considered"mad" buttheonesI have encounteredhavenot sufferedfrom amentalillnessas definedby psychiatrists,butfromseverepersonalitydisorders.There is nodoubtthat severepersonalitydisordercan resemblementalillness,butthe treatmentimplicationsof the distinctionare enormous.

4.17 The PCL-Rwouldhave improvedtheprobationofficers'riskassessmentsbutonlymarginally.The reportsreferto manyof the factorsthat contributeto anassessmentof psychopathy,includinglack of remorse,etc.

4.18 Itemsderivedfrom the PCL-Rare partof OASys,theOffenderAssessmentSystem.

4.19 The PrisonServiceis developinga strategyfordealingwith psychopathicprisoners,includinga PsychopathyProgramme.There is evidencethatconventionaloffendingbehaviourprogrammesincreaseoffendingrisk inthosewitha highscore on the PCL-R. The PsychopathyProgrammeis beingdevelopedwithinthe OffendingBehaviourProgrammesUnit,by psychologistsandwithlittleor no medicalinvolvement.

4.20 Doctorsplaylittleroleinthe managementof psychopathyand risk in mostprisonsystems.Forexample, inSaskatoon'sRegionalPsychiatricCentre,the treatmentis supervisedbypsychologistsandpsychiatristslimitthemselvesto detectingandtreatingconcomitantillnesssuchas depressionor schizophrenia.

4.21 The PCL-Rwouldhavevalue as a screeningtestwithinthe prisonsystem,and itis usedbyforensic(notclinical)psychologistsas partof sentenceand riskmanagementwithinthe longterm adultprisonsystem.It is resource intensiveand may notbe cost-effectivein short-termprisoners,wherethe detectionrate(highscores)wouldbe low.There wouldalsobe reservationsaboutapplyinganysuchinstrumentto youngoffenders,where thereis oftena morechangeablepictureovertime. Hare has developeda versionof the PCL for youngoffendersbut ithas notbeen widelyused.

-2101-

4.22 Recent research work in adolescents has focussed on the concept of lifetime-persistent v. adolescence-limited delinquency. The large mass of youngoffenders who will grow out of their offending hides a core who will continue tooffend throughout their adult lives and will often qualify for the label ofpsychopathy. Although the killingwas not foreseeable, Stewart was identifiableas both a psychopath (in the Hare sense) and as a lifetime-persistent offender,but there are no current arrangements for identification or management of thisgroup, unless they come to attention through a particular offence or a longsentence. This is criminology, not medicine.

I confirm that insofar as the facts stated within my report are within my own knowledge Ihave made clear which they are and I believe them to be true, and that the opinions Ihave expressed represent my true and complete professional opinion.

A Maden MD MRCPsychConsultant Forensic PsychiatristApproved under Section 12(2) of the Mental Health Act 1983

-2102-