Nearly four years after Richard Linford battered to death Christopher Edwards in a prison cell in Essex, there has been little improvement in local care in the community services; if anything, the pressure on psychiatric beds is worse.
The independent inquiry, which cost more than pounds 1m and took three years to complete, adds that mentally ill people who do not take medication should be compelled to have treatment. It also says that a review of care in the community "should be delayed no longer", otherwise "the pattern of tragedy followed by inquiry" is doomed to continue.
Mr Edwards's parents said prisons must no longer be used as a "dumping ground" for the mentally ill. They also called on the Home Secretary to investigate their allegations that the police and prison service had tried to avoid any blame for Christopher's death.
On 29 November 1994 Mr Edwards, who had been diagnosed with psychiatric problems, was taken to Chelmsford prison after he accosted a woman in the street. Half an hour later Richard Linford was brought in. He had been fighting and was initially considered unfit to be housed with other inmates. "Had each been allocated a single cell this tragedy would not have occurred," says the report.
But within an hour Linford was sharing a cell with Mr Edwards. He knocked Mr Edwards to the ground then jumped repeatedly on his head until his skull was crushed. Mr Edwards could only be identified from his dental records. Linford later admitted manslaughter and was sent to Rampton special hospital.
On the night of the tragedy neither of the men should have been in prison, but in hospital, the inquiry said.
However, there were no secure beds available. Crucial information about their mental health was not passed on. No one was clear whether either of the men was dangerous. The alarm system in the cells had been tampered with so 17 vital minutes elapsed before staff were alerted. "By the time prison officers entered the cell . . .[Edwards] had been kicked and stamped to death."
It was not just Mr Edwards that the system failed. Community care for Linford as his mental condition deteriorated was "abysmal", the inquiry said. A month before he killed Mr Edwards a doctor concluded after examining him that "he could actually murder someone".
No formal risk assessment was carried out and Kieran Coonan QC, chairman of the inquiry, noted: "It is a pretty depressing comment to make but in November 1994 Linford's care was limited to a sympathetic ear and occasional assistance with shopping from an unqualified care assistant who should never been allowed to visit him at his flat alone."
Linford had refused to take his medication and the inquiry concluded that the law should be changed so that similar cases can be taken into hospital for compulsory treatment.
The Department of Health's White Paper on mental health is due out in weeks. A spokesman for the National Schizophrenia Fellowship cautioned against compulsory treatment: "It will damage the therapeutic relationship. People who are well think they will be treated like criminals and people who do not take their medication are even less likely to keep in touch with services. Legally there are likely to be problems."
Yesterday, theEdwards family backed the bulk of the report's recommendations. "A sense of outrage needs to be brought to the surface," said Christopher's father Paul. "I don't think the community will accept prisons as a dumping ground for the mentally ill."Reuse content