Andy Duffy
Psychiatric patients treated and released by Western Cape health authorities have killed seven people over the past 18 months, including two children, amid an apparent collapse in the system set up to monitor them.
The former patients, all from the high- security forensic unit at Cape Town’s Valkenberg hospital, represent a small proportion of the mostly harmless population of state mental and psychiatric institutions.
But the killings could fuel fears about the government’s drive to release thousands of patients into the care of their family and friends. Health officials say community care has been hit by staff shortages and cost-cutting measures such as voluntary severance packages.
The deaths could also leave state health open to huge legal and civil action from the victims’ families.
Valkenberg forensic unit head Sean Kaliski says the six patients who turned killers were all judged to be rehabilitated and low risk prior to their release. The unit treats patients who are deemed unfit to stand trial for crimes such as murder, rape and assault.
But he adds that an exodus of state psychiatric nurses and social workers holed the safety net designed to catch the relapses among discharged patients. Valkenberg only discovered the homicidal activities of its former patients from police inquiries throughout last year.
Their victims were mainly family members. One man buried a hatchet in his stepdaughter’s chest, another stabbed his mother. The children – two small girls abducted, raped and killed in the Free State – are believed to have been random victims of one former patient. All have been caught.
Kaliski adds that the unit also releases dozens of other patients for a month at a time because the hospital lacks the staff to control them.
“We just hope to God they don’t hurt someone while they’re out,” Kaliski says.
The killings caught national and provincial health officials off guard. The Department of Health had to check with Valkenberg before issuing a written response.
“Patients released from forensic units of mental institutions sometimes do commit crimes of varying seriousness,” department director for mental health and substance abuse, Melvyn Freeman, says. “This is, however, the exception rather than the rule.”
Other institutions report that less than 5% of their released patients commit crime.
Freeman adds the department would have to consult its legal advisers to check whether it can be held liable in criminal or civil law for the deaths.
The Western Cape health chief director of supraregional hospitals, Gilbert Lawrence, says the killings are a “wake-up call” about the weakness of current community care.
“Doctors [at Valkenberg] face the dilemma about releasing patients into a structure that is adequate or not adequate. At the end of the day it’s a question of resources. It’s happening across the country.”
Around 735 staff at the province’s four psychiatric and mental institutions have taken pay-offs since June 1996, close to one-quarter of their total staff. More than 420 have taken the package in the past six weeks.
The staff losses form part of an overall health rationalisation and cost-cutting programme. The province also plans to close Valkenberg, transferring its services and staff to three surviving state institutions.
Kaliski and Dr Brian Robertson, head of the psychiatric department at the University of Cape Town, believe the closure could further weaken the care given forensic unit patients. Valkenberg is one of UCT’s teaching hospitals. “I’ve no doubt it will increase the risk,” Robertson adds.
Lawrence says that is just an opinion; he expects the rationalisation will improve care.
Valkenberg treats 280 forensic unit patients – 65 of them in a maximum-security unit -from the Western, Eastern and Northern Cape. The unit discharged 33 patients between 1996 and 1997, following lengthy, gradual rehabilitation.
The discharge application is approved by the attorney general – in Valkenberg’s case, Frank Kahn – following consultation with a judge.
Valkenberg all but froze the release process late last year, as the killings mounted. Kaliski estimates that discharged patients have now killed at least 11 people over the past three years. Many of them have since been returned to the institution.
“Either we’ve got to watch them closely, or someone else must, but we have great difficulty keeping an eye on everyone,” Kaliski adds. “The only way we can keep control of them is to keep them in our walls.”
He says the unit is unable to gauge what sort of treatment, if any, other discharged former patients are receiving.
Adequate community care will be vital in preventing the government’s drive toward releasing state patients ending in a smash. The government’s main motive is to modernise its approach to mental and psychiatric health care, away from often grotesque past practices such as simply locking patients away.
But similar experiments overseas have left many former state patients on the streets or in jail. Such results prompted the United Kingdom recently to reverse its care-in-the-community policy.
The Western Cape based its rationalisation plans partially on a task-team report finalised earlier this year.
The report warned that community care for psychiatric and mental patients, already hampered by staff shortages, had been further hurt by voluntary severances. It recommended that posts vacated under the pay-off programme be retained and filled.
But the department responded that it could not “guarantee” the posts would be retained. “Cognisance must be taken of the need to rationalise the total health department to set budget limits,” the department noted.
Freeman says community care in the Western Cape “has not collapsed. However, there is little doubt that these services could be improved.”
Lawrence adds that the province will only release patients into the community “at a rate that can be received”. At the moment, such patients are being moved into halfway houses.