Mental health professionals never engaged therapeutically with a patient in the four years before he randomly stabbed six people in London, an inquiry found.
An independent investigation into the treatment of Ismail Dogan, now 34, diagnosed with paranoid schizophrenia, revealed treatment only ever involved anti-psychotic medication.
He was never offered any psychological help during his four psychiatric in-patient admissions. This was in spite of Dogan’s parents requesting psychotherapy for him in 2002.
In March 2006 Dogan was found guilty of attempting to kill five people in the street in London in December 2004. He admitted the manslaughter, by stabbing, of Ernest Meads, 58, on the grounds of diminished responsibility and was committed indefinitely to Broadmoor psychiatric hospital.
Barnet, Enfield and Haringey Mental Health Trust and Haringey Teaching Primary Care Trust were the centre of the investigation by NHS London.
“The failure to engage with Mr. Dogan is a hallmark of the care and treatment that he received,” read NHS London’s report.
“The investigation team considers this to be a significant factor that runs throughout all of the other critical issues and causal factors identified.”
Before the stabbings, Dogan had stopped taking anti-psychotic medication six months earlier and said he could hear God telling him to stab people.
He was well-known to mental health services.
No fewer than 23 “critical junctures” were identified in Dogan’s care and treatment.
Other key findings include:
• Dogan’s parents tried five times to ask for help as he became increasingly violent but no help was forthcoming, partly because the mother could not speak much English and healthcare professionals only called in translators “sporadically”.
• Non-existent communication between in-patient and out-patient departments.
• Poor communication between the police and the health trust.
In a joint statement, the two trusts said: “In the years since 2004 we have made significant changes to improve clinical governance and risk assessment, care co-ordination and inter-agency communications.
“We have developed our policies which set standards and expectations for our staff in relation to clinical supervision and we audit these policies to ensure they are properly implemented.
“There have been no homicides in Haringey committed by people receiving care from mental health services since the incident involving Mr. D in 2004.”