Mental Health Services Criticised on Tube Killing

Mental health services were found yesterday to have failed to assess the risk of discharging a man with a serious personality disorder who carried out a murder on the London Underground. Stephen Soans-Wade, a drug addict with a long history of mental health problems, could not have been clearer in the warning he gave to psychiatrists before pushing a stranger to his death under a fast-moving tube train at Mile End station in east London.

“I feel like I’m going to do something. I’m going to push somebody under a bus or a train unless I get help. I’m not safe,” he told doctors in the A&E department at the Royal London hospital in Whitechapel.

He was admitted to the nearby St Clement’s hospital, but nobody did a risk assessment before discharging him.

Four days later in September 2002, he stepped up to Christophe Duclos, a French security guard, on the platform at Mile End, and pushed him into the path of a train. Mr Duclos died a few days later. Soans-Wade was jailed for life in 2004 after the Crown Prosecution Service rejected his claim of diminished responsibility and a jury found him guilty of murder.

Yesterday an independent inquiry identified a catalogue of failings by mental health and social services that may have contributed to the tragedy. It found that Soans-Wade, 39, had a history of violence and drug dependency, including heroin and crack cocaine. His problems included a psychotic disorder, possibly schizophrenia, mental and behavioural disorders caused by drug use, and various personality disorders.

In the six weeks leading up to the killing he tried to get himself admitted to hospital three times and visited his GP twice. Hours before he pushed Mr Duclos to his death, police officers took him back to hospital after becoming concerned about his claim that he heard voices telling him to do “bad things.” But he did not wait for medical attention.

The inquiry, led by Clare Price, a barrister, found a breakdown of communications between hospital psychiatrists, community mental health teams, staff in the drug dependency unit, social services and family doctors.

Soans-Wade calmed down after admission to hospital, but became agitated as soon as he was discharged. This may have been linked to a fear of returning to his flat, which had been taken over by drug-taking acquaintances.

Miss Price said: “We could not identify a single individual or team that was responsible for coordinating his care. Nobody had an overview of his chaotic behaviour … We found no risk assessment and poor documentation. Nobody in our view formed a comprehensive assessment of the threats he was making. There was a clear risk that violence would escalate.”

The inquiry did not pin blame on any individual and could not say whether Mr Duclos’s death could have been prevented. It avoided any suggestion that Soans-Wade’s mental state raised doubts about the murder conviction.

But Miss Price said lessons had to be learned from the case. There were clear dangers that people with personality disorders could become “revolving door patients” – regarded by hospital psychiatrists as untreatable, but seen by GPs and community mental health teams as dangerously vulnerable.

She called for a specialist personality disorder unit to be set up in north-east London. Other recommendations included a review of treatment for patients with a “dual diagnosis”, involving mental illness and drug problems.

Alwen Williams, chief executive of Tower Hamlets primary care trust, said it had appointed a lead nurse for dual diagnosis, and services for people with personality disorder were one of this year’s top priorities.

Carolyn Regan, managing director of NHS London, which commissioned the report, said: “In the four years since this incident, a greater understanding of the needs of people like Stephen Soans-Wade has been developed and services have been developed that are better able to meet these needs.”

But Marjorie Wallace, chief executive of the mental health charity Sane, said the inquiry demonstrated a repeated failure by psychiatric services to protect patients and the public.

“When someone clearly suffers from a mental disorder, it is extraordinary that they are turned away, as in the case of Stephen Soans-Wade to take another man’s life … This is the community care policy at its worst,” she said.