ALR

First things first: this post is much longer than my average post — you may want to make sure you’ve got a cuppa on hand before you start.  There is simply a lot to cover and discuss, I’m afraid.

Last week, two reports were published relating to Alexander Lewis-Ranwell (ALR) who killed three men in Exeter in February 2019.  The first relates to his mental health care (referring to him as ‘Mr A’, throughout) and another covers the multi-agency responses to offending behaviours exhibited by him, not just in 2019.  Mr Lewis-Ranwell was found not guilty by reason of insanity of the three murders in Exeter and was sentenced to a restricted hospital order which means he is now detained in Broadmoor Hospital.  Given his contacts with many public organisations in the days and years prior to the index offences, reviews were undertaken.  Inquests are still pending in to the deaths of the victims and the BBC has summarised the reports in their coverage.

In addition and a little incidentally, Mr Lewis-Ranwell is now suing four organisations for failing to ensure adequate treatment and care for him arising from the 48-72hrs prior to the killings of the elderly victims in Exeter and this has proved noteworthy as one of civil law is that someone cannot bring legal action which allows them to profit from criminal behaviours.

Of course, Mr Ranwell-Lewis has argued through his lawyers that he was found not guilty of the offences – albeit not guilty by reason of insanity.  It was an option for a court to convict him or manslaughter on the grounds of diminished responsibility – still be a criminal conviction – but the jury found instead he was legally insane and therefore not criminally responsible for his actions.  As such, the High Court and the Court of Apppeal has ruled he is free to bring his civil claims against Devon Partnership Trust, Devon County Council, Devon and Cornwall Police and G4S (who provided medical services in police custody).

The civil claim is still pending (no timeline known), along with the inquests for the victims.

TWO REPORTS

For ease of reference —

• I will refer to the mental health care report as “the MH report”;
• I will refer to the mult-agency review as “the CJ report”.

ALR had a history of offending and mental health care inc hospital admission going back to 2016 and  earlier.  The MH report documents he was a cannabis user, not always compliant with his medication and that he had been admitted under the  Mental Health Act 1983 (MHA) to a psychiatric intensive care unit (PICU) in 2016 where he had been subject to forensic assessment after setting fire to a wardrobe and causing other damage.  He was diagnosed with paranoid schizophrenia, albeit his diagnoses changed during the course of treatment contacts in the three years which followed.  His non-compliance with medication did mean he disengaged from services, something flagged as a concern to mental health services by his partner.  In August 2017, he was arrested for an offence during which he assaulted a police officer and was assessed under the MHA but deemed not to be in need of admission.  Three days later, arrested in London for dangerous driving, he was assessed again and then admitted to a PICU under s2 MHA — this later became detention for treatment under s3 MHA.  Reports written during this period suggest there was a “high probability he would act in a dangerous way on discharge” (p9, the MH report).

After discharge he had no further contact with mental health services until February 2019 and the events prior to the three killings then come in to focus —

• 8th Feb – he was arrested for burglary and seen in police custody by Liaison and Diversion mental health services (L&D) who decided against the need for a Mental Health Act assessment, something with which the MH crisis team concurred.
• He was released on police bail, pending further investigation for that burglary.

• 9th Feb – he was arrested for GBH on a farmer after attacking him with a logging saw.  L&D triaged his case over the phone but were not able to undertake a face-to-face assessment because he was being held in Barnstaple custody and the nurse was based in Exeter.
• They asked the force medical examiner (FME) to see him face-to-face instead, stating they thought a Mental Health Act assessment would be required (p34, the MH report).
• The FME did this and following telephone discussion with an AMHP from Devon County Council, it was decided a Mental Health Act assessment was not required, despite the nurse’s expressed view.

• 10th Feb – ALR was released from police custody in Barnstaple around 0938hrs.
• Three men were killed in Exeter that day.

• 11th Feb – ALR was arrested for public order, assault and offensive weapons offences at an Exeter hotel around 0530hrs.
• He was taken to police custody where he was further assessed under the MHA and admitted to a psychiatric intensive care unit under s2 MHA.
• I have to assume the offences alleged on the 11th were either subject to no further action or subject to bail but wasn’t released because of the s2 MHA admission to a PICU.

• 12th Feb – whilst in hospital, the police linked him to the three killings in Exeter on the 10th February and arrested him from ward for murder, the doctor rescinding his s2 detention as he was returning to custody.
• At his subsequent trial for the various offences, ALR was found not guilty by reason of insanity and given a s37/41 restricted hospital order.
• “We found that a number of elements of Mr A’s mental health care and treatment could have been managed differently” (p14 and p26).

• There is a detailed time line of specific arrest times and disposal decisions on p32 of the MH report.

The report asks questions about why criminal charges were not followed up by the police in 2016 after the wardrobe arson incident with one psychiatrist involved at that time arguing it would be “detrimental to Mr A not to proceed with a criminal investigation because he would learn that he could get away with such behaviour” (p23, the MH report).  The CJ report doesn’t really say why they weren’t. They both further highlights that mental health care decisions taken in the crucial days prior to 10th February were taken on incomplete information.  The G4S healthcare staff – contracted by the police and not the NHS – were not privy to the medical history and background information held by the NHS.  As such, the doctor who spoke to the AMHP was not fully aware of ALR’s history which documents serious risk incidents and non-engagement over the previous three years.

POLICE CUSTODY

Because ALR had been seen in police custody on the 08th February after arrest for burglary, it was initially assumed he would not need to be seen again on the 09th following his arrest for GBH.  The police had to specifically request him to be seen but as above, the nurse was in Exeter so unavailable to do so.  It was documented in both reports that police and the NHS expected him to be charged with the serious GBH offence and that they took the investigation to the Crown Prosecution Service for a charging decision around 0140hrs 10th February – the CPS declined to prosecute, requesting more information to make their decision.

After investigators requested consideration by a senior officer of an extension to the time limit on ALR’s detention in police custody, a superintendent declined to authorise it, directing instead his release on bail with conditions, to secure the additional information required by CPS.  Extensions can only occur when two criteria are met: that there is not enough evidence to charge and that detention is necessary to secure further evidence. For reasons that are not explained in the CJ report, the superintendent’s denial of the extension at 0300hrs on the 10th Feb did not lead to ALR’s release from custody until 0938hrs on the 10th – almost 7hrs later.  It’s not made precisely clear in the report what the purpose of that detention was if it’s being stated there is insufficient evidence to charge him with an offence and no justification for keeping him in custody for further investigation (hence, the superintendent’s direction to release him on bail with conditions).

The CJ report then documents there are seven disposal options from custody in the case of ALR —

• 1. PACE extension: i.e., more time in custody to complete the additional investigative actions set by CPS.
  2. Charge with an offence and remand to court –
  3. Charge with the offence and bail to court
  4. Release from custody and utilise section 136 MHA
  5. Conduct a Mental Health Act assessment (MHAA) resulting in hospital admission.
  6. Release under investigation without charge (RUI)
  7. Release with no further action (NFA).

In reality, there are many more than seven outcomes because many of the above could be combined: indeed some of the seven above unavoidably lead to others:  if you extend the detention (option 1), you must eventually still do one of the other six things.  If you charge with an offence and bail, you could still utilise section 136 MHA.  If you conduct a MHAA it may not result in admission, so you also still end up having to do one of the other things like charge or release.  It’s overly simplistic to suggest that one thing from those seven would be the outcome.  It could be that two or three things from the above are the “outcome” because option 1 is not a disposal outcome at all and option 5 is not a disposal outcome for the offence either.  Someone who is assessed as requiring MHA admission can still be charged and if they’re not, they’d still be release, either RUI, bail or NFA!

THE CJ REPORT

When I first heard the outline of this case during the criminal trial, mention was made of a duty inspector documenting his view on the custody record prior to ALR’s release on 10th February because there were serious concerns about further offending. The inspector noted in a formal review of ALR’s police detention the “detained person presents a serious risk to breach the public if released”.  Given ALR had not had a mental health assessment by a specialist and given the L&D nurse and the AMHP involved in discussion of his detention had not physically seen him that day, it led me to wonder whether the police had considered utilising s136 MHA on release from custody?

The CJ report addresses this, I was relieved to see, stating this option was considered. Discussion about use of s136 (p39) led to it being discounted for two reasons, the report authors state —

• “He would need to be de-arrested to apply the section 136” – actually, this is simply not true.  Nothing in law prevents use of s136 on someone who is already arrested at the time of the decision to use the MHA power, assuming the criteria are met.  The report goes on “there was a risk he could not be re-arrested if he was not detained after the MHA” – well, then: manage it differently:
• The PACE clocks stops if you transfer someone to hospital and then if the s136 concludes that MHA admission is not required, the 136 ends and you can remove the person back to custody.
• Also, it was presumed the police were likely to secure a criminal charge, hence s136 was not used – but that doesn’t address the question of why s136 wasn’t then revisited as an option once it was known there would be no charge after CPS review.

• The report also states were concerns about safely conveying him to the Exeter Place of Safety – but it goes on to state “the police have assured this review that operational issues would not have influenced decision making about conveyance to Exeter”.
• So was it discounted for this reason or not?  This doesn’t really make sense to me – the report is stating it was discounted for this second reason “according to L&D”, but the police assured this wasn’t a factor.  So was it actually a factor or was this just the (unfounded) opinion of one L&D professional?

• The report does make a recommendation about policy revision of joint protocols between agencies on the topic of s136 MHA in custody — You will have to infer from that what you think is right, because I don’t see the need for that revision explained if the report is very satisfied that non-use of s136 was “absolutely right”, as claimed.

There are some minor points about these reports which also make me call in to question attention to detail.  Firstly, the AMHP’s who read these documents will need prepare for the acronym being incorrectly explained in full – AMHP means “Approved Mental Health Professional”, it is a legally protected term from the MHA itself.  The document refers more than once to “Approved Mental Health Practitioners” – a minor point you may argue, but it speaks to detail.  Furthermore, the claim made on p46 about Code C of the Police and Criminal Evidence Act 1984’s Codes of Practice is simply not correct:  Code C does not provide “the police with a set of rules that they must adhere to” [my emphasis].  A Code of Practice is not binding instruction, it is a suite of statutory guidelines which should be complied with to the extent they can be but there is a fundamental distinction to be understood here about the law (ie, PACE itself) and the statutory guidance which accompanies it (ie, the Codes of Practice).  Elsewhere on this blog I have written about situations where the police simply cannot comply with Code C, no matter how hard they try to do so, with respect to vulnerable people in custody.  Having tried their best and failed, this is not inherently unlawful because it is a breach of a Code, not a breach of the law itself.

The confusion about what is law and what is guidance continues in para 5.53 of the CJ report – PACE Code C does nothing whatsoever to set the duration police can detain someone.  Such legal time limits comes from PACE itself and there are various important legal reasons why this distinction is not just legal pedantry on my part.

SECTION 136

Paragraph 5.106 of the CJ report is key in many respects to this, from what I have available to read in these reports and from what else is known in media coverage of the criminal trial. It relates to the release of ALR and non-use of s136 MHA at that point —

“Against the decision not to make Mr A subject of Section 2 of the Mental Health Act, there was no Mental Health [sic] legislative framework in place to detain him further.  The purposes of any police power such a Section 136 of the Mental Health Act is detention for the purpose of assessment.  As mental health practitioners had already made the decision that a mental health assessment was not required there was no legitimacy in utilising this legislation.” (p55)

I’m afraid this is simply not correct and I claim this on advice because this precise debate has come up more than once before.  The fact a doctor or other MH professional has been asked to conduct an assessment and declined is not, of  itself, a barrier to police use of s136; and the purpose of section 136 is not just about assessment, as claimed in the quote above. Assessments of patients can occur in a variety of circumstances which do not involve s136 or arrest by the police, in fact most mental health assessment are done without police involvement.  The primary purpose of s136 is to keep people safe now who aren’t safe now; either by keeping patients safe from self-injury or suicide or keeping others safe from violence or homicide by patients.  And yes: to then assess what support they may required, whether or not they are ‘sectioned’ after an assessment.

There are two aspects to s136 MHA – subsection (1) and subsection (2).  They are two distinct powers, in law with these related purposes —

1. Subsection (1) — obviously,  this has to come first: it’s about detention of some at imminent risk because it is believed they are in immediate need of care or control, either in their best interests or for the protection of others.  Do we think at 0938hrs ALR was suffering a mental disorder? – yes. Do we think detention may be necessary to protect others? – yes (because the duty inspector had documented this concern on the custody record at some point prior to release).
2. Subsection (2) — this relates to detention at a Place of Safety after removal under subsection (1) by the police.  It is about detention for the assessment which the report claims is the only purpose to detention: it’s not.  The overall purpose is the maintenance of safety, pending that assessment.  As long as officers using s136 still believe some kind of further assessment needs to occur, they are at liberty to act if they believe the person is in immediate need of care or control.

So why would the police detain someone for further mental health assessment if a doctor in police custody who discussed the case with an L&D nurse and an AMHP has decided against it?  Well, potentially a number of reasons:

1. You’ll remember the L&D nurse did say they felt ALR needed an MHA assessment, albeit they concluded this from a telephone triage and not face-to-face. Mental health nurses do not play a formal, legal role in MHA assessment for compulsory admission (but they do gate-keep the need for MHA assessment and are experienced at it) — so, one reason to push for something which ensures full, face-to-face mental health assessment is that no mental health professional had seen this man in-person assessment and face-to-face assessment is key in the MHA, there is case law on this point.
2. We know the doctor in custody doesn’t have access to NHS background / NHS records – this has been the case in most areas for decades, so we should always assume non-NHS healthcare staff in custody could be blind to various things, unless specifically reassured otherwise.  Assessment may be required to ensure those taking decisions are not blind.
3. We also know that the need for assessment can quickly change – ARL himself was assessed on 14th August 2016 and not sectioned; assessed again on 17th August 2016 and he was, to a psychiatric intensive care unit.  There are other examples of people being assessed twice in much shorter timeframes where the second conclusion was at direct odds with the first.
4. We know the duty inspector who conducted the PACE review was seriously concerned about future offending, if released; whether or not that inspector knew all of the above three points and whether or not the inspector knew that the first rule of any good mental health assessment is a physical / visual assessment of the patient. He was seriously concerned and documented the fact in a legal record.
5. We know that NHS and MH risk assessment of the need for compulsory admission can be very wrong – the Chief Coroner’s website is littered with examples of under-response by mental health services to risks of harm.  It’s something also repeatedly flagged in literature and by campaigning groups like Inquest or Hundred Families.

EXPERTS

Finally, we already knew something in 2019 which was highlighted in a quite separate homicide inquest in Birmingham.  In 2018, Mr Khalid Yousef was killed in Birmingham, leading to an inquest in 2022.  Prior to the killing, the perpetrator had been in police custody for a less serious offence, seen by L&D with consideration around whether or not he needed to be ‘sectioned’.  It was decided against that course of action, leaving the investigating police officer concerned for further serious offending, much as the duty inspector had been in the ALR case.

The investigator did not escalate those concerns because of a belief that expert professionals had taken the decision and the police had no option but to proceed with a course of action they honestly believed to be risky.  As the coroner laid bare in the Preventing Future Death report (and based upon expert witness evidence), the police should not consider L&D professionals to be ‘experts’ per se and should be escalating concerns where they have them.

I submit the same could be said of this case and do think, for that reason, that one way of escalating concerns is consideration of using s136 to mitigate the immediate risk to life or risk of serious injury on release and to ensure that specialist mental health professionals actually see the man in person as part of an assessment under s136(2).  We only need to look at the difference of views taken on the 14th and 17th August 2016 with ALR when he was assessed twice in a short time frame to see obvious potential that professionals can take different views of the same patient and that consideration of these issues can change in just a few days, or less.

And they can charge with tragic outcomes which in general terms, were somewhat predictable because we do know that at least some of the people involved in this case were, in fact, predicting.

NB: this post is a reaction to nothing other than the two published reports, reflecting on their content – it is not a reaction to any of the incidents themselves or offering any comment on investigations or enquiries, past or present.

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Winner of the President’s Medal,
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award

 

All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2023

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I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current.  Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.

Government legislation website – www.legislation.gov.uk