Its report, published yesterday, exposed a catalogue of failures by individuals and the community care system in the case of Michael Buchanan, a paranoid schizophrenic who killed a stranger in an underground car park.
Buchanan, now aged 30, is a drug addict who also suffered from a psychopathic personality disorder. He attacked Michael Graver, a 54-year-old former policeman, when he was parking his car in Harlesden, north London, in September 1992. Buchanan hit him about the head with a piece of wood and stamped on his face, causing 13 severe multiple fractures to his facial bones. Mr Graver died two days later in hospital. Buchanan was jailed for life in July 1993 after admitting manslaughter due to diminished responsibility.
Christopher Heginbotham, chairman of the inquiry team, said yesterday that the Department of Health should review its guidance to psychiatrists, who are divided over whether people with personality disorders are treatable or not. Otherwise, more potentially dangerous people who suffer from personality disorders would go untreated and remain a threat to themselves and the public.
The Buchanan killing bears chilling similarities to the case of Christopher Clunis, a paranoid schizophrenic who killed an innocent bystander on a London Underground station after being discharged from a psychiatric hospital. The Buchanan report reveals perhaps even graver mistakes than those revealed in the Clunis inquiry. The Buchanan inquiry found that because he was disruptive and threatening on the ward he was often discharged ``rapidly'' from hospital by medical staff who knew he could not cope in the community and was dangerous.
Mr Heginbotham said: ``The tendency is to say, `There is nothing we can do to help him,' and he is discharged time after time, an offence waiting to happen. We are seriously concerned that there are other people like him who may offend in the future and there is very little we can do about it.''
Mental health charities were outraged by the failures exposed by the inquiry. The National Schizophrenic Foundation said: ``The catalogue of failures in this case continues as Michael Buchanan still has not been found a hospital bed. Although being diagnosed a schizophrenic he languishes in a prison cell.''
John Bowis, a health minister, said: ``Sadly, it seems a combination of poor compliance by the patient with plans for aftercare, combined with inadequate planning by the multi-disciplinary team responsible for him, led to things going disastrously wrong.''
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