The Abbeylara standoff, in which John Carthy was killed, has been the subject of much media comment, most of which has concentrated on the actions of the Garda. There has been relatively little analysis of the fact that the victim had a history of clinical depression. With publication of the reports of the Garda and FBI inquiries imminent, how might Carthy's history of mental illness have influenced the management of the crisis?
John Carthy had a long history of depression. According to his sister, Marie, his only in-patient admission was to Mullingar Hospital one-and-a-half years ago. His ongoing treatment was in Dublin, however. John Carthy had very good insight into his illness. He talked openly about his feelings and, when he began to feel unwell, he made appointments to see his psychiatrist. In fact he had an appointment in Dublin on Holy Thursday, the day he died.
Unlike the UK, we have not had to deal with many incidents such as Abbeylara. This lack of experience showed as the tragic events of Holy Week unfolded. Would the outcome have been different if John Carthy had lived in rural Britain?
Each county constabulary in the UK has a tactical weapons unit which deals with situations such as Abbeylara. Included in the team which responds are trained negotiators of inspector rank or above. Standard operating procedures stipulate that two such negotiators be at the scene of any incident within one hour. In addition, an intelligence officer is dispatched to gather information on the person's psychological and criminal history. Each constabulary has a force psychologist who can be called on to attend the siege and who will provide psychological profiling as well as negotiation advice.
When it is clear that the besieged person has a history of mental illness, the nature of the response will immediately change. Armed officers will be pulled further back and the area of containment enlarged so as not to place unnecessary pressure on an already highly stressed individual. Officers will be instructed not to respond even if fired upon. Put simply, the officers will be told: "Only shoot if you have to."
Such an approach is a reflection of the mental health training which armed response units in the UK receive. Typically, officers receive mental health awareness training modules from their local NHS Trust. This enables them to differentiate between schizophrenia and depression, for example. Officers are taught the signs and symptoms of mental illness and, in some areas, are even afforded the opportunity to interview patients with different diagnosis, in much the same way as medical students learn psychiatry.
In many respects, however, the tragic outcome of Abbeylara has its origins in events and policies which predate the siege itself. Just as a person who suffers a heart attack can trace the origins of heart disease back in time, John Carthy's state of mind at the time of his death evolved due to a lack of preventive systems going back many years.
First, Carthy chose to attend a Dublin hospital, an understandable reaction to the stigma which can still surround psychiatric illness in this country. The standard of care he received was second-to-none, but a Dublin hospital would not have the resources to support a former patient in a county more than 70 miles away. It can be a difficult enough challenge to maintain and support a patient in the community, even for local psychiatric and primary care services.
Under 1945 legislation (a new Act is making its way through the Oireachtas at present), the transfer of a person back to in-patient care is fraught with legal and practical loopholes. The system relies on skilled community psychiatric nurses picking up early signs of deterioration and encouraging the patient to return to hospital for further treatment.
This State lacks a comprehensive system for detecting the early signs of deterioration in a psychiatric patient in the community. In the UK, a patient such as Carthy would have been slotted into a system created by the 1983 Mental Health Act.
According to Dr Damian Mohan, a consultant forensic psychiatrist in Berkshire, the focus of the inquiry into Abbeylara should have been on why and how the incident had developed to such an advanced stage, rather than on the actions of gardai and health professionals at the scene. "It is likely that, faced with such a high-risk situation, they had no alternative but to adopt the course of action that they pursued," says Dr Mohan. "In analysing the antecedents of the incident, rather than asking whether it was appropriate for the ERU (Emergency Response Unit) to have been called or not, in my view it would be much more useful to know if there were monitoring systems and safeguards in place, not only to detect early warning signs of a deterioration in mental state, but also an appropriate and accessible clinical service that would have provided early assessment and treatment. Abbeylara could be seen as a symptom of a healthcare service that failed to adopt a care approach."
Mohan points to the Care Programme Approach (CPA) which has been adopted as statutory practice in the UK following a series of community care disasters in the early 1990s. The CPA requires health authorities, in collaboration with social services, to put in place specific arrangements for the care and treatment of mentally ill patients in the community. It specifically requires that a worker be appointed to keep in touch with the patient, and it stipulates that a system of regular review by a multi-disciplinary team commence following discharge. The issue of the patient holding a gun licence would have been addressed in this context.
While the CPA does not guarantee the prevention of future violent incidents by mentally abnormal individuals, it nonetheless sets a national standard of clinical practice, the cornerstone of which is the sharing of clinical information.
A 1995 amendment to the UK Mental Health Act introduced the further concept of "after-care under supervision". Under a supervised discharge, the patient is required to comply with certain conditions. The amendment is less draconian than it sounds and is itself subject to regular review and challenge.
However, in combination with the CPA, the "supervised discharge" system makes it virtually impossible for a person with mental illness to arrive back in the community without adequate medical and social support. Such a system may have prevented John Carthy reaching the point where he saw barricading himself into his house as the only option.
Another useful UK practice is the creation of supervision registers. As well as providing for patient supervision, they can act as the basis for information exchange with enforcement agencies at times of crisis. People on the supervision register include those with severe and enduring mental illness. The possibility of a significant suicide risk, causing serious harm to others or severe self-neglect are typical reasons for entering a patient on the register.
A written assessment of the risk of a psychiatric patient causing harm to another person is also an integral part of the UK system. As in other aspects of life, psychiatric risk can never be eliminated. However it can be rigorously assessed and managed. In addition, the outcome of the assessment can be shared with a third party (for example the police) where the need to protect the public outweighs the duty of doctor-patient confidentiality.
The Garda needs to look at its own procedures and practices where the mentally ill are concerned. At present the force has no formal arrangements with health professionals. The benefits of involving such professionals at a siege or hostage situation should be considered. Research shows that police agencies using a mental health professional as a consultant report more incidents ending by negotiation and fewer requiring a tactical assault.
So, would John Carthy be alive today if he had lived in the UK? We will never know the answer to that question, but we can reach the following conclusions with some certainty.
A properly structured system of community psychiatric care would very likely have reached out to Carthy as his psychological health began to fail in the weeks leading up to Easter. And, although it is impossible to prevent all barricade situations arising, a system of effective crisis management at the scene would have greatly reduced the likelihood of a fatal outcome.
John Carthy is another victim of the State's failure to legislate for the proper care of disadvantaged groups in society.