Sign of the Times
Transparency needed to help identify flaws in a system
While the case barely received any media coverage in Japan, in September, a certain serial murderer made headlines all over Britain. Surprisingly, the murders took place over five years ago and the murderer has already been arrested. So why all the media attention now?
As it turns out, the perpetrator was mentally ill and the crimes took place because of a series of flaws in the system that treated him.
Peter Bryan, who has been sentenced to life imprisonment for three murders and suffers from schizophrenia, was sent to Rampton Secure Hospital after he beat a 20-year-old shop assistant to death with a hammer in 1993. He was discharged in 2001 and moved into a hostel to receive community care. In 2002, however, he assaulted a 17-year-old girl and was once again hospitalized, but in an open ward.
The second murder took place in February 2004. Bryan escaped from his hospital room, killed a 45-year-old acquaintance, chopped his body into pieces, and ate parts of the man's flesh. The case involving "madness" and "cannibalism" sent shockwaves through British society.
Bryan committed his third murder after he was arrested and sent to Broadmoor Hospital, a high-security psychiatric institution, by strangling a 59-year-old fellow inpatient.
Britain requires an independent inquiry under the guidance of the Department of Health when a mentally ill patient receiving treatment commits a crime. On Sept. 3 this year, the National Health Service (NHS) disclosed the results of two investigations that were conducted regarding Bryan's case.
The report states that the series of events were not attributed to errors made by specific individuals, but that they were due to systemic failures.
When Bryan was discharged from the first psychiatric hospital to community care, he only received six months of rehabilitation training, even though the standard program takes two years. In addition, the staff in charge of community care was inexperienced, and was quick to decrease Bryan's medication dosage.
A more experienced expert may have been able to identify the danger Bryan posed at the point at which he assaulted the teenage girl. If Bryan had at least been placed in a high-security institution instead of an open ward, the second murder could have been prevented.
There have been charges of sloppy management against Broadmoor over the murder that took place there. Bryan was not adequately examined upon hospitalization, and when the attack took place in the dining hall there were no staff members present. From the report, it's clear that the system was inexcusably flawed.
But the most important lesson we can take away from this is that the NHS conducted an exhaustive five-year investigation to clarify where the responsibility for the case lies, and made the results available to the public. Upon a quick look through the report, I found that not only did the investigative panel conduct a meticulous inquiry, it also offered 50 detailed recommendations to the respective responsible parties.
British psychiatric care is not, of course, picture-perfect. It suffers from a constant shortage of psychiatrists and high-security hospitals are overflowing with patients who have recovered but cannot be discharged. Furthermore, prisons are filled with mentally ill individuals who are not given treatment.
Even if a system's flaws cannot be corrected right away, however, certain things can still be done. That is, the flaws of a system can be identified, specific ways for improvement laid out, and the information then made public and recorded. In order to bring transparency to a system, efforts to increase visibility and document information are essential.
As non-fiction writer Kunio Yanagida pointed out in his writings about airplane accidents, investigations into crimes and accidents in Japan still tend to focus on finger-pointing. Moreover, information about incidents that involve the mentally ill are generally concealed, citing reasons of privacy. What fills in this dearth of public information are tabloid magazines and tell-all books.
However, systemic accidents -- of which airplane accidents are a typical example -- are a result of a chain of multiple causes. In order to prevent such incidents from taking place, a thorough investigation of systemic glitches -- not the assignment of blame -- is what matters. In that sense, there is much to be learned from the NHS report as a model of systemic inquiry in the mental health field.
Although the crime rate for mentally ill individuals is far lower than that for those who are not mentally ill, the perception that such people are "dangerous" still runs rampant. As it is, there exists the prejudice that crimes committed by the mentally ill are distinct in some way, and hiding information only serves to enhance this view. Information must be made public in order for us to regain tolerance.
The American psychiatrist Thomas Szasz once said, "The stupid neither forgive nor forget; the naive forgive and forget; the wise forgive but do not forget." I'd like to believe that we, as people who are unforgiving but forgetful, need one more effort, if we want to be wise. (By Tamaki Saito, psychiatrist)
(Mainichi Japan) November 16, 2009