As to why this system had failed in Graham’s case: ‘The clinical history was unique. Poisoning is an uncommon crime and a case of this nature – by a boy of immature and disturbed personality – is unique in forensic psychiatric experience. The opinion formed by the doctor was reasonable in relation to the facts available to him at the time.’
Positing the question ‘Can an assurance be given that Young will never again be released?’, the review declared: ‘Obviously no absolute assurance can be given about the view that might be formed, many years hence, by a future Home Secretary (acting on the advice of the Parole Board). But it is clear that it is out of the question at present to think of Young’s possible release.’ The review also passed final judicial comment on the question of Molly Young’s murder, when it stated that ‘this has not been substantiated and no action can be taken’.
Pointed questions were asked about Graham’s mental state and whether, if he was still regarded as ‘mentally disordered’, his condition might be curable. The review answered: ‘This is not a question on which a layman can enter into details – it is understood that he appears to have an abnormality of personality which is not susceptible to psychiatric treatment.’ There were also several very succinct replies to some questions that had been repeatedly raised in the press, such as whether disciplinary action was being contemplated against any of the individuals involved, to which the response was a flat ‘No’. Regarding the issue of ‘Who took the actual decision to discharge?’, the review refused to say, stating: ‘It is not the practice to disclose the identities of individuals acting in the name of the Home Secretary. The decision was taken at a high level.’
Returning to the wider issues raised by the case, question 56 asked: ‘The system is being improved: in what ways was it inadequate? There seem to have been big loopholes: is not the stable door being shut after the horse has gone?’ The answer given stated that the resettlement of patients from the special hospitals into the community had been ‘remarkably successful’, but the close examination given to the general procedures had revealed the need for ‘a well-understood code of procedures’, including the improvements mentioned in the ministerial statement.
To avoid similar cases, the committee suggested that ‘the social worker who is likely to supervise [the discharged patient], and the local consultant who will be taking over responsibility for the medical aspect of treatment if the patient is going to an area distant from the treating hospital, should be brought into consultation at an early stage. Not only will this enable the decision about discharge to be taken with the best possible knowledge of the likely circumstance, but it will allow time for the patient and those who will be concerned in the follow-up process to become acquainted with each other and the problems which they will be facing.’727 This could best be achieved, it was felt, by an extended use of case conferences, which would involve the relevant professionals:
Assessment of individual patient’s personality, the nature of his mental disorder, his response to therapeutic help, the circumstances, both material and emotional, in which the offence took place, the likelihood of those circumstances recurring, the resources available in the social situation the patient would go into on leaving hospital, the likely reactions to that situation, and the chances of his successful reintegration in the community despite any stresses which may develop.728
The use of case conferences would also help maintain a vital balance between what was best for conditionally discharged offenders and the right of the public to be protected. At that time, rehabilitation was a major aim – if not the primary aim – of those agencies concerned with managing offenders; it was a common belief that such people should be able to move forward, and indeed perhaps could only move forward without having to disclose their history, since that was regarded as a burden that might prevent their successful reintegration into society. In Graham’s case, a perfect storm had been created by the absence of coordination between the various agencies involved, leaving him free to realise his ambition of becoming an infamous poisoner.
The code of procedures suggested was introduced as a direct result of the review and covered a number of changes in the after-care and follow-up of conditionally discharged patients as a result of the review. The key amendments were:
We now look, at the time of discharge, for more information than in the past about the social setting in which the patient will live after discharge.
We ensure that the supervising officer (and the local consultant psychiatrist who undertakes medical surveillance, if he is not the responsible medical officer) is fully briefed on the medico-social history of the patient and on his responsibilities.
Consideration is now given to whether, and how much, the patient’s employer, landlord or others need to be told about his past.
Reports by the supervising officer are now sent to the Home Office direct rather than through the former responsible medical officer, and we look to the local consultant psychiatrist for reports at similar intervals. Copies of the reports by each are sent to the other.
We ensure that the police force for the area in which the patient is to live are aware of his presence.729
Other conditions, not made public at the time, were implemented regarding cases requiring a patient’s urgent recall to hospital; these in effect gave the Home Secretary complete power over such situations. Ultimately, the Aarvold committee found that ‘from our enquiries we are satisfied that the case was dealt with in accordance with the procedures accepted at the time to ensure that proper weight was given to questions of public safety.’
1972–1990
PARKHURST
‘Life is always dangerous – never forget that.
In the end, perhaps, not only great forces but the work of our own hands may destroy it.’
AGATHA CHRISTIE, THE PALE HORSE
(COLLINS, THE CRIME CLUB, 1961)
Chapter Twenty-seven
A POISON TEMPER’D BY HIMSELF
A
LTHOUGH THE RECOMMENDATIONS of the inquiry were implemented immediately, there were soon instances where all the safeguards failed.
Six months after the publication of the Aarvold Report, Graham’s case and the flaws that had led to it were linked in the press to the breakdown of Genevieve Parslow, granddaughter of a police officer and a 29-year-old Buckinghamshire mother of two, who had suffered severe mental health problems. She had spent several periods in care; during one stay at a mental health facility, she had become pregnant by another patient. Doctors refused to allow her to have an abortion on the NHS and therefore she arranged the procedure privately. Her mental health deteriorated rapidly again as a result and, one weekend in March 1973, she tried to poison her children by feeding them jam contaminated with cleaning fluid. When her husband discovered what she had done, he made her leave the house. After wandering about the streets all night, she made her way to Aylesbury police station and pleaded with an inspector for help. She informed the startled inspector that she was a witch more than 1,000 years old and that it was her destiny to ‘kill everyone in the world’, especially babies. The inspector asked if she was fond of her own children. ‘No,’ Genevieve replied, ‘They ought to be dead, like me.’ Local mental welfare officials were called in, who in turn sent for a GP, 27-year-old Dr Adrian Burch. He talked to two doctors from St John’s hospital at Stone, where Genevieve had had two spells of treatment. But all three thought it unnecessary to admit her to hospital again, believing outpatient treatment was a better option.
Genevieve then walked away from Aylesbury police station, where, according to the prosecution at her subsequent trial, it had not been possible legally to detain her. What happened next would forever scar all those involved in her case: Genevieve somehow made her way approximately five miles south-east to the pretty market town of Wendover. In Nash Lee Road, she approached a bungalow and looked through the window, where a ten-week-old baby lay sleeping in his cot. She climbed through the window, snatched the child and
carried him to a ditch half a mile away. There she drowned him before stamping on his body.
The baby was Jonathan Snasdell, the younger son of television film editor David Snasdell and his wife Vanessa, both 25 years old. They raised the alarm and their child’s body was discovered that afternoon, in the ditch where Genevieve had killed him. Genevieve herself was located in a private garden shortly afterwards. She was tried at Reading Crown Court on 18 July 1973. Pleading not guilty to murder, she admitted manslaughter on the grounds of diminished responsibility, a plea that the prosecution accepted. Mr Justice Thesiger sent her to Broadmoor and ordered that she should not be released from strict security ‘whatever doctors or tribunals recommend’. Genevieve Parslow died 40 years later at a care home for those with ‘challenging behaviours associated with complex neurological, physical and mental health needs’.
In the wake of the trial, Vanessa Snasdell offered to adopt Genevieve’s son and daughter and raise them with her own. She told reporters: ‘If the doctors had given Mrs Parslow the help she clearly needed, I would still have my baby. The police officers had done their best and they could see she was not fit to be left wandering around. Refusing as they did, these foolish doctors are guilty of crass stupidity. They should have been made to appear in court to explain their decisions.’ Dr Burch moved away after the trial but told those reporters who tracked him down: ‘The reason I did not certify her that night was simply because at the time she was not certifiable. As a doctor I will listen to the advice of others when dealing with a case. But in the end I have to make my own decision and that is what I did with Mrs Parslow.’ The Snasdells were promised a full inquiry by the medical director of Stone mental hospital (as it was called then), although he admitted: ‘Knowing only what the doctors then knew, I would not have recommended that the patient be detained. If we had thought that this woman would harm someone, it would have been a different matter.’730
The case gained widespread attention in the media. Referring to the Graham Young case, an editorial in the Daily Express declared:
Once again the failure of those charged with securing the mentally disturbed is exposed. A mad woman, Mrs Parslow, killed a baby boy . . . The public is becoming increasingly alarmed at the number of unbalanced people who are being freed, or being given diminished sentences, at the say-so of psychiatrists . . . Psychiatrists are not omnipotent. Their prime duty must be to the interests of society. But society too has a duty: to provide comprehensive facilities for the care of those who have long periods of lucidity along with recurring bouts of murderous obsessions. Here is a branch of medicine which is being starved of resources – at the public’s expense.731
Another article titled ‘How We Can Cut the Mad Killer Menace’ thundered: ‘This is the third case recently when people known by psychiatrists to be mad have killed. Poisoner Graham Young murdered shortly after his release from Broadmoor and 38-year-old psychopath Wesley Churchman was recently jailed for life for a killing he committed several years after serving a six-year jail sentence for murder.’ The newspaper suggested a three-point plan that was more or less an echo of the recommendations of the Aarvold committee, advocating a full and adequate treatment programme worked out for each mental patient; the strengthening of community services – health visitors and social workers – who should remain in close enough touch with their charges to identify any relapse and a consultant psychiatrist on hand for swift assessments in acute situations. The column ended: ‘Psychiatrists must realise their responsibility cannot end once they have discharged a patient from hospital. A closer surveillance must be kept on doubtful patients once released.’732
Some of the press was plainly inflammatory, but agreed the responsibility had to lie with those in the relevant branch of medicine, declaring:
The streets of Britain are filled each day with thousands of mentally disturbed people . . . when does a disturbed person become a dangerous lunatic? It is normally left to the welfare services to alert the community to the hazards that accompany mental disorder. Social workers with close first-hand knowledge of families are trained to spot the potentially dangerous people . . . But nevertheless at the end of the day the responsibility lies with the medical men. We must put our trust in their training and their judgement.733
But the ink was scarcely dry on the newspaper reports of the Snasdell killing before another Broadmoor-related case reached the media. Terrence Iliffe had been sent to Broadmoor in September 1970 for the attempted murder of his second wife. Three years later, aged 53, he was conditionally discharged. The hospital had declared him to be no risk to the general public, but ‘If Iliffe were to remarry, there might be a specific risk to his wife.’ The Aarvold recommendations were in place, putting him under supposedly strict supervision, but he managed to remarry clandestinely. Three weeks after the wedding, neighbours raised the alarm when he and his new wife suddenly seemed to vanish. Police who broke into his home in Swanage found Iliffe severely injured and his wife’s body in the freezer. He had strangled her. In hospital, Iliffe was found to be suffering from acid poisoning.
At Winchester Crown Court, Iliffe made no attempt to deny strangling his wife, who was his third. He was convicted of murder and sentenced to life imprisonment; he died in 2002, aged 81, while still serving his sentence. The case was raised in a House of Commons debate in January 1976, when MP Michael Alison stated that there was ‘real, noticeable and widespread public disquiet’ over mentally disordered offenders.734 He referred to Graham Young, Terrence Iliffe and Ian Dunlop.
The latter, who had spent all but three of his 39 years in institutions, was admitted to Broadmoor for sex offences in 1964 with – like Graham – a restriction order for 15 years. In 1973 he was transferred to a prison on medical advice. After four months, he was allowed out to work as a plumber and was given periods of weekend leave. A female acquaintance contacted the prison to warn that Dunlop had been paying ‘abnormal interest’ to her seven-year-old son. Dunlop was interviewed by a medical officer who accepted his insistence that the claim was untrue. The Home Office likewise accepted the doctor’s report on the matter. In May 1975, a family with whom Dunlop was lodging twice called Broadmoor to express concern at the former patient’s behaviour towards their children. Nonetheless, the responsible medical officer decided this did not affect his advice to the Home Office that Dunlop was suitable for conditional discharge. But the following month, Dunlop went on leave and failed to return. He was eventually captured, but by then he had committed 13 offences against young boys and was jailed for life after admitting the offences, which included abduction, wounding, assault and acts of gross indecency. His own defence counsel stated that allowing him out of hospital was like letting a mad dog loose and expecting it not to bite.
Five years after the Dunlop case, the British press was filled with the story of 44-year-old labourer Ronald Sailes. He had spent 16 years in Broadmoor on a rape conviction and was released in November 1978. Seven months later in Plymouth, he killed 16-year-old Anita Quayle, leaving her gagged and mutilated body on a sun-lounger. Sailes had been released on the recommendation of Dr Edgar Udwin. When reporters discovered that this was the same doctor who had recommended the conditional discharge of Graham Young, they did a little more research and found that six men who had been released on Udwin’s recommendation had gone on to commit major crimes. However, it has to be borne when considering such cases that we rarely if ever hear of the successes, only the failures – but these failures can be deadly.
Dr Udwin was made physician superintendent of Broadmoor in October 1981; he had been running the hospital since McGrath retired earlier in that year after 25 years in charge. Newspaper articles on his appointment noted that he was a controversial figure for his decisions in the past. Udwin held the post for only 18 months; he retired in 1983.
The findings of the Butler committee had first appeared in an interim report in 1974 with its final form published in October 1975. Its official remit had been to consider to what exte
nt and on what criteria the law should recognise mental disorder or abnormality in a person accused of a criminal offence as a factor affecting his liability to be tried or convicted, and his disposal; and to consider what, if any, changes were necessary in the powers, procedures and facilities relating to the provision of appropriate treatment in prison, hospital or the community for offenders suffering from mental disorder or abnormality, and to their discharge and after-care. One hundred and forty recommendations were put forward, including several for the psychiatric hospital systems, of forensic psychiatry and in regard to the insanity defence.
The interim report appeared because the members of the committee were so appalled by their findings, particularly with regard to gross overcrowding in the special hospitals. In some Broadmoor wards there was barely a gap of 18 inches between beds. The report declared: ‘Patients obviously have no privacy. And as there is no cupboard room, they are living out of suitcases.’735 The committee urged an immediate overhaul to improve conditions, leading Social Services Secretary Mrs Barbara Castle to promise the House, ‘We shall remedy the overcrowding at Broadmoor as soon as possible.’736
The report further warned: ‘Between the overcrowded but secure special hospital and the National Health Service hospitals providing no security, there is a yawning gap.’ Secure units were recommended for all 14 regional health authorities to relieve pressure on special hospitals but would also allow the NHS to concentrate on those patients who would most benefit from an ‘open door’ regime, relieving prisons of some of the more disturbed inmates. The committee believed there were around 500 patients in special hospitals who had no need to be there. Barbara Castle pledged between £12 and £14 million to begin an early programme of building to provide units for 1,000 patients, which was half the number deemed necessary by the Butler committee. A new unit at Maghull near Liverpool was almost complete; this would become Park Lane hospital, later Ashworth, whose most infamous resident was Moors Murderer Ian Brady. Fifty-eight beds would also be added to Rampton. A new hospital at Broadmoor to replace the present one was expected to be completed by 1979; it finally opened in 2019.
A Passion for Poison Page 35