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Revulsion against a killer, driven by insanity or ideology, who murders innocent people at random, fuels irresistible public demands for the perpetrator to be punished and for those, usually NHS mental health workers or police who failed to prevent some horrific acts of violence, to be held to account.
The cases of Valdo Calocane, who stabbed to death three people in Nottingham in 2023, and Axel Rudakubana, who knifed three children to death and injured many more in Southport in 2024, have generated intense but baffled fury about why individuals with such dangerous track records were allowed to roam the streets before murdering their victims.
A new judge-led public inquiry into the Nottingham attack was announced this week, which Sir Keir Starmer says is important so witnesses could “answer questions about their actions and their decisions”. The families of the dead – Barnaby Webber, Grace O’Malley-Kumar, both 19, and Ian Coates, 65 – had demanded a statutory inquiry so witnesses could be compelled to give evidence.
Devastated families of the dead understandably want somebody held responsible for the loss of those they loved. But we already know in some detail what went wrong and that individuals made culpably wrong decisions. But blaming everything on them simply evades seeking to mitigate or resolve the crisis in the UK’s mental health care.
It is not just that the system is bad, but that many changes since the 70s have made it worse. It has been damaged by a pincer movement from those, generally on the right, who do not want to spend money on expensive mental health hospitals and those, most commonly on the left, who believe it wrong to lock people up or force them to take medication.
‘Couldn’t care less in the community’
Over the last half century mental asylums have closed one after another to be supposedly replaced by “care in the community”. Speaking of this, the detective story writer PD James, an administrator in the NHS whose husband was a long-term patient in a mental health hospital, remarked bitterly that “it could best be described as absence of care in a community still largely resentful or frightened of mental illness”. A former health minister, John Hutton, said a better name for it would be “couldn’t care less in the community”.
Psychiatrists are divided on the degree of coercion necessary or acceptable to treat patients. Medications exist that control but do not cure mental illness, but should people be compelled to take them against their will? Is a person with a psychosis able to make rational decisions about their treatment?
These are not merely academic questions. Criticism of the NHS treatment of Calocane focuses on the degree to which he was allowed to make judgements about his mental illness, though he denied being ill. Jeremy Coid, professor of forensic psychiatry at Queen Mary University of London, says that mistakes in Calocane’s treatment include “allowing him to disengage from services at times when he was too ill to make rational decisions and when he was paranoid and suffering from acute symptoms”.
Diagnosis in mental illness is almost never as precise as it is in physical illness. “Our predictive ability to determine if a patient might commit an act of violence is almost zero,” a forensic psychiatrist of great experience told me. “Statistically, most of those mentally ill people who go on to kill have been assessed as low risk.”
The problem is that joining up the dots retrospectively of a mentally ill person’s behaviour before they go on to kill gives a misleading impression of blameworthy failure to detain an obviously dangerous person before they do harm to others.
But very few of those with these toxic patterns of behaviour go on to hurt anybody. Every year around 50,000 people in England are sectioned – confined in a hospital with or without their agreement – because of mental health issues. “Just how many of these people does society want to detain permanently?” asks the forensic psychiatrist, particularly since there is an acute shortage of beds for psychiatric care patients in the UK, reduced by 25 per cent to 23,782 since 2010.
Psychiatric doctors come under intense pressure from hospital managers to discharge patients prematurely in order to free up desperately needed beds.Many changes suggested for the NHS’s mental health system contained in a new Mental Health Bill now passing through Parliament have the potential to make a badly flawed system even worse, says Professor Coid. He believes that “psychiatry is in a terrible state in the UK”, pointing to a shortage of 13,300 nurses and 963 consultants.
Chronic shortages of staff
The new bill seeks to enhance patient choice, including a provision for patients, when well, to spell out how they wish to be treated when they are ill. This is surely absurd because so many of the sickest people I have encountered in the mental health system deny there is anything wrong with them. Specialised “advocates” acting on the patient’s behalf would be able to challenge the decisions of doctors and social workers, though it remains unclear who is going to train these people in a complex system with chronic shortages of staff.
My own experience of the NHS mental health system, gained while looking after a relative suffering from schizophrenia, is that the new bill is unrealistic. The problem for many trying to do their best for a sick family member is that they cannot get them into a hospital where they will be safe. A century ago people might be incarcerated for far too long, but today the problem is precisely the opposite and they are discharged too early, often making way for “discharged failures”, who left hospital too early for their treatment to work.
Mistakes will always be made in psychiatry because diagnosis and treatment are far more uncertain than in physical medicine. But errors are exacerbated by a lethal combination of inadequate resources and surging demand.
The frightening real world of psychiatric care in the UK is best understood by looking at a timeline drawn up by the Care Quality Commission detailing Valdo Calocane’s [VC] interactions with mental health services in Nottingham on a single day, 22 October 2021, after he had been discharged from hospital:“VC’s family contacted the EIP [Early Intervention in Psychosis] team expressing dissatisfaction at not being informed that he was being discharged. The discharge happened on a Friday with no crisis home treatment team input arranged over the weekend. The EIP team attempted to make a referral to the crisis resolution and home treatment team but they were unable to accept VC due to capacity due to an ‘influx in GP referrals over the weekend’.”
No wonder terrible mistakes are made in such a ramshackle system. But doctors know this will be no defence if one of their patients commits homicide. “Some doctors routinely write that ‘this man could kill somebody’ in their notes in case something goes wrong,” says the forensic psychiatrist.
Some of the best, most committed people in Britain work for NHS mental health – but it is a system set up for them to fail.
Further thoughts
A feature of living under an authoritarian government is that even lowly state functionaries pose a threat. In Turkey, I watched for years as President Recep Tayyip Erdoğan cumulatively increased his grip on the levers of power. Then, after the failed military coup in 2016, the media, army, judiciary, civil service and the entire state bureaucracy were abruptly purged. Dissent became risky. People making the mildest critical comment about the state of the country to me would insist that I should not quote them by name – in fact, much better if I did not quote them at all.
A Turkish writer friend told me an anecdote about themselves at that time which perfectly illustrates the anxiety that many feel in this type of increasingly authoritarian state.
The writer was passing through passport control at Istanbul airport, when the official examining their passport looked startled and suddenly said: “Please wait for a moment.” My friend felt their heart sink, and suspected something disobliging that they had written about the government years earlier had finally caught up with them, and they imagined the prison gates yawning wide before them.
Then the passport official popped up beside my friend and said: “I really like your writing. Could I have a selfie with you?” The writer gave a sigh of relief and agreed, but in that moment decided that “if one of my fans almost gives me a heart attack, I can’t stay in Turkey any longer”. They left the country soon afterwards and, so far as I know, have never returned.
I wonder if, in the not-so-distant future, Americans returning to the US will have the same uneasy feeling as they pass through passport control on their way to New York or Washington? A paradoxical aspect of President Donald Trump’s Maga movement’s populist-nationalist-authoritarian ideology is that in some respects it makes the US similar to countries like Turkey, India, Hungary and other “managed” democracies.
These are not classic dictatorships and they do have real elections, but the full weight of the state is deployed to skew the election result towards a cult-like leader and his ruling party by control of the media, state bureaucracy and state money. Once firmly cemented into power by these advantages, regimes become difficult to evict.
This point is well made in an article titled “The Path to American Authoritarianism: What Comes After Democratic Breakdown” by Steven Levitsky and Lucan A Way in Foreign Affairs magazine. They say that the modern authoritarian state does not rely primarily on physical force, but on its capacity to “determine who gets prosecuted for crimes, whose taxes are audited, when and how rules and regulations are enforced, which organisations receive tax-exempt status, which private agencies get contracts to accredit universities, and which companies obtain critical licenses, concessions, contracts, subsidies, tariff waivers, and bailouts”.
The US federal government has two million employees and an annual budget of $7trn (£5.5trn). Once weaponised in favour of the ruling party these will be difficult to resist and opposition will be marginalised; “politics becomes like a soccer match in which the referees, the groundskeepers, and the scorekeepers work for one team to sabotage its rival”. The winner of the game is not in doubt.
The craven response of European leaders to President Trump’s threat to ethnically cleanse Gaza of 2.3 million Palestinians caused no surprise since these same presidents, prime ministers and foreign ministers could not even raise a collective bleat of dissent against his threat to seize Greenland, which belongs to EU member Denmark. Trump’s proposed peace talks with President Putin have put the Europeans states in the humiliating position of demanding that they should at least be allowed a place at the peace conference table.
The best account of European humiliation that I have read is by Mukul Kesavan in India’s The Telegraph Online.
In an excoriating piece, he writes that “watching America’s Western allies respond to Trump’s proclaimed intention to annex Greenland and the Panama Canal, make Canada the 51st state and take over Gaza and turn it into the Riviera has been an education. The abject way in which rich, seemingly sovereign, nations tiptoed around Trump’s provocations suggests that the liberal international order is principally a patron-client system where America is the hegemon and other Western nations choose to be luxury protectorates. Russia’s invasion of Ukraine and Maga America’s insistence that it be compensated for the protection it extends have reduced these countries to kowtowing petitioners in Trump’s court.”
Cockburn’s Pick
At a moment when there is so much under-informed discussion about mentally ill people making murderous attacks at random, the best book I have read relating to the subject is What We Fear Most: A Psychiatrist’s Journey to the Heart of Madness by Ben Cave.
This is Dispatches with Patrick Cockburn, a subscriber-only newsletter from The i Paper. If you’d like to get this direct to your inbox, every single week, you can sign up here.
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