Inquiry into the Care and Treatment of Sarwat Al-Assaf
In November 2000, Sarwat Al-Assaf killed his wife's new partner. Mr Sarwat Al-Assaf was a deaf man living in Nottinghamshire. Although he had been in contact with mental health services, his plea of manslaughter on the grounds of diminished responsibility was rejected. He was found guilty of murder in July 2001.
The Report of the Independent Inquiry into the Care and Treatment of Sarwat Al-Assaf looked at the events leading up to the murder. This is the normal procedure because Sarwat Al-Assaf had involvement from mental health services before the homicide.
Sarwat Al-Asssaf was profoundly Deaf since the age of three. Originally from Egypt, he came to the UK aged 19 to attend the Royal School for the Deaf in Derby. He went on to technical college and received a qualification in electrical engineering.
While in the UK, Sarwat Al-Assaf learnt British Sign Language (BSL). Following a first marriage, Sarwat Al-Assaf married again in 1997. His new wife was hearing but communicated in BSL. Unfortunately, Sarwat Al-Assaf started gambling and got himself into debt. This led to the family home having to be sold, and the couple separated for a time in 1999. In 2000 they moved back in together but problems with the debts remained.
In September 2000 Mrs Al-Assaf said she wanted a divorce. Sarwat Al-Assaf was very upset and made cuts to his wrists. He became more distressed and began to hyperventilate. An ambulance was called and Sarwat Al-Assaf was taken to the Accident & Emergency Department.
Care and treatment
Sarwat Al-Assaf was assessed at the Accident & Emergency Department. Staff used Mrs Al-Assaf to interpret. This posed huge problems for all concerned. Sarwat Al-Assaf was being asked questions such as "Do you want to harm your wife and child?". Mrs Al-Assaf was having to sign this and then - when necessary - give information back to the clinicians. It is worth quoting from the Report:
"The use of a family member for the purposes of interpretation may, though not intentionally, lead to inaccurqate, biased or incomplete reporting, particularly where it concerns sensitive issues or experience of, belief about, and reactions to, risk. The Mental Health Act Code of Practice advises against it. Yet Mrs Al-Assaf interpreter for her husband on five occasions that night. She described to us her feeling that she was not listened to in her own right, commenting that she had been asked to interpret for her husband when it involved clinical questions about possible risk to herself from him. She told us she was 'worn out'."
The Report also makes a crucial observation.
"Staff in AED, the Clinical Nurse Specialist from DPM, the ward staff on A43 and the duty SHO all believed that it was not possible to obtain a sign language interpreter out of hours. This was incorrect. There was a contract for the provision of emergency signers for the Deaf with the Nottinghamshire Deaf Society. That service was available until 11pm on Friday evenings and could have been accessed by any of the professionals. This was, and still is, a little known service which should be publicised more widely throughout the QMC [Queen's Medical Centre]."
The Report also made clear that psychiatric assessment of a Deaf patient is extremely difficult. The Inquiry felt that in such circumstances, consultation with senior colleagues is important.
Following this incident, Sarwat Al-Assaf was seen by various health professionals. These included Emmanuel Chan, a specialist CPN who works with Deaf patients in Nottingham. Following another incident, when Sarwat Al-Assaf poured petrol over himself, he was seen again at the hospital. This was 'out-of-hours' when no interpreter was available. Staff relied on written notes being passed between themselves and Sarwat Al-Assaf. This led to a confused communication. However, he was admitted and became settled on the ward. It was felt that Sarwat Al-Assaf was not suffering from a mental illness and there were no grounds for detaining him under the Mental Health Act.
After discharge, Sarwat Al-Assaf received support from various people, including staff from the County Deaf Team. He was assessed as not being a risk to either himself or others. Staff acknowledged that he was finding it hard to cope with his wife leaving and adjusting to this.
On 7th November 2000 Sarwat Al-Assaf kept his appointment with Mr Chan. He appeared "calm and pleasant". What Mr Chan did not know is that the homicide has been committed the day before. Mrs Al-Assaf's new partner, Alan Clarke, was found with multiple stab wounds. The Report said that following the homicide there were no further signs of mental illness reported while Sarwat Al-Assaf was in prison. The consensus of experts called by the Inquiry was that Sarwat Al-Assaf experienced an "adjustment disorder". Whether this could be considered a "mental disorder" under the terms of the Mental Health Act is debatable. The Report said that, "We cannot conclude that a decision not to use the Act was inappropriate at the time."
The Report concluded that the killing on Alan Clarke was unpredictable, and that, "Even with hindsight it was a surprising outcome."
Although the killing was unpredictable, the Report still found that improvements could be made and offerered a number of recommendations. These included:
- Ensure that a contract is in place to provide 24 hours sign lanaguage interpretation when needed at the AED and psychiatric wards of QMC.
- Provide information about this service clearly displayed in AED and on each ward and with the QMC switchboard.
- Produce guidance to all staff on how to use the service, why they should use it and the problems associated with the use of relatives for interpretation, citing the Code of Practice at paprgraph 1.6. Reference should be made to the need for Deaf individuals to receive basic information on admission and legal rights under the Mental Health Act, as well as ensuring appropriate clinical assessment.
- Commission a 24 hour regional emergency service for Deaf people suffering from mental health problems, to be accessed by minicom for those who are Deaf or by telephone for hearing professionals or relatives. The service should be capable of providing advice to Deaf users, professionals and relatives, ensuring that local services are appropriately accessed and interpretation services obtained.
- Develop alongside this service a program of Deaf Awareness induction training for all new medical staff.