Prof Harry Kennedy, our guide through the Central Mental Hospital and its clinical director, tells us to move quickly through the ward. He must have detected some worry on our faces as he immediately adds that there are no safety fears. Most of the people in the ward have committed violent crimes – some have killed people – but the very fact they are in ward three, a medium security part of the hospital, means they have reached a stable stage in their treatment.
Kennedy wants us to move quickly because we don’t have permission to interview the patients. But we immediately bump into one man who is eager to chat.
Hearing we're from The Irish Times, he laughs. "My case was all over The Irish Times." Kennedy introduces another man who tells us he is a fan of the newspaper's business section.
I ask if he ever listens to the paper’s podcasts. “What’s a podcast?” asks a third patient who has joined the group. The others tell him it’s a kind of radio show but on the internet. “Internet access would be a issue here,” Kennedy says quietly.
Patients have access to computer classes with limited internet access but safety concerns prevent it being made more widely available.
The Central Mental Hospital (CMH) was built in 1852, and its Victorian features can be seen everywhere. Before we continue our tour, Kennedy is eager to show us a few of the ward’s anachronisms. He points to a hatch set high above the doorway of a cell.
“That goes back to the gaslight days. At night the attendant went around with a lantern on a pole. They would put the lamp in the opening to light up the cell from the outside and look in through the little window to check that people were still breathing and that they were still there.”
Then he points to the metal frame of the door which has two sets of hinges. All the cells used to have double doors, he explains. “Anti-psychotic medication really only became available in the 1950s, so for years there was no medication. People would just scream and scream and they were tormented. The extra door was for silence.”
The hospital, located on 34 acres of well-groomed lawns (“I keep telling the gardeners they are artists,” says Kennedy), sits behind an 18-foot wall just outside Dundrum village in south Dublin.
Victorian asylum
From the outside – and to a certain extent on the inside too – it looks every bit the Victorian asylum. In fact it was built on similar plans to the notorious Bethlem Royal Hospital in London, more commonly known as Bedlam. The CMH is fascinating from a historical and architectural point of view but as a modern mental health facility it is completely unfit for purpose.
“It’s been condemned as not fit for purpose since the 1990s, when the Council of Europe Committee for the Prevention of Torture came independently from abroad and inspected us,” says Kennedy.
Although many of the people here have committed violent acts, they are not here to be punished. The philosophy is “patients, not prisoners”. As he shows us around, Kennedy does his best to play down the more custodial features of the facility. He doesn’t always succeed.
Every time we reach a door he has to find the right key for the ancient metal Chubb lock. “Anytime RTÉ come here, they want to record the sound of the key turning and the door closing. It’s a wonderfully Gothic sound.”
Inside he points to various features that could be used for suicide attempts, many of them impossible to hide because of the three-foot-thick granite walls.
In the stairwells patches of damp and peeling paint are visible. “As soon as we paint the walls they start to peel again,” the professor complains.
As for the patients’ rooms, they are small, plain and don’t quite meet the minimum standards set by the Committee for the Prevention of Torture.
It’s not all bleak. The patients in the medium- and lower-security wards can decorate their rooms as they wish. The corridors are wide and large windows let in lots of light.
Kennedy explains that this is because the hospital was built on Victorian ideas that fresh air and sunlight were vital for treating those suffering from mental illness.
“This was all you had then. There was no medication. All you had was the regime. That meant air and light and food. And of course the farm was very active so you had fresh food, fresh air and daylight. A very different system.”
Final days
These are the final days of the Central Mental Hospital in Dundrum. It’s scheduled to move into a modern facility, St Ita’s in Portrane, by 2020.
The new facility will be like a hotel compared with Dundrum, Kennedy says. Most significantly, it will be able to handle 170 inpatients instead of the current 94, including 10 beds for adolescents and 20 beds for women.
The most typical patient is a man suffering from schizophrenia who has stopped taking his medication and has killed a family member – often a parent
The hospital was to be moved to the Thornton Hall site in north Co Dublin, where the Government was to build a new “super-prison” – but this was abandoned after opposition from patients’ families and hospital staff, who said sharing a site with a prison would only add to the stigma. “It would have sent out the wrong message entirely,” Kennedy says.
Kennedy has been promised by previous governments that money from the sale of the site will be reinvested in the mental health sector, although there are now also calls for the land to be used for social housing. Its location in an affluent suburb near the Luas line means it could fetch a price in the hundreds of millions.
Until 2020, there is insufficient space at the facility. Currently there are approximately 25 severely mentally ill people waiting to be transferred to the hospital from prisons, but are stuck where they are because there are too few beds in Dundrum.
There are three types of patients in the CMH. There are those who come here through the criminal justice system, usually after a verdict of not guilty by reason of insanity. A small number of these have been sent here before trial for assessment of their mental state.
Mohammed Mori, the young man accused of murdering Japanese student Yosuke Sasaki in Dundalk in January, falls into this category (he remains in the high-security section of the hospital and has been deemed unfit to attend any of his court dates so far).
Then there are those transferred from other psychiatric facilities because of their violent or aggressive behaviour. And last, there are those who have been convicted in the courts and sent to prison but then transferred to the hospital because of severe mental illness.
Forensic patients
More than the archaic building, capacity is the main issue facing the hospital. Ireland has two beds for forensic patients (the official term for mentally ill people in the criminal justice system) per 100,000 people. The UK has 10 per 100,000, while the Netherlands has 14. And even with the new facility in Portrane the Irish number will only be about 3.5 per 100,000.
This means people in the prison system who are extremely ill often cannot be admitted. This endangers prison staff, fellow inmates and the prisoner themselves, and has already caused injuries.
And it means Kennedy has to make ethical decisions on which patients to accept based on how much of an immediate danger they are.
Kennedy says it will probably take a major tragedy before the situation is properly addressed. “An Irish solution to an Irish problem. Manage only by crisis. Never anticipate.”
The situation is made harder to swallow because there’s an entire ward lying empty in the hospital. It has been refurbished but there are not enough nurses to staff it.
The issue isn’t that people don’t want to work in the CMH, Kennedy says. “We are a very popular recruiter when we are allowed to recruit. People relish a challenge.”
The problem is HSE restrictions on recruiting and the fact that there are not enough qualified nurses in the country.
It wasn’t always like this. After the end of the second World War, when governments were starved of cash, it became fashionable to close down secure psychiatric facilities in favour of treating sufferers in the community.
It was a welcome move, especially in Ireland, which – as the late Mary Raftery has written – at one point locked up more people per head of population than the Soviet Union, the vast majority of whom did not need secure care.
One of the main proponents of this seemingly enlightened move was Enoch Powell, the English Conservative politician famous for his “rivers of blood” speech. Among psychiatrists, Powell’s most famous speech is not the one condemning immigration but what is known as his “water towers” speech.
“There they stand, isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside – the asylums which our forefathers built with such immense solidity to express the notions of their day,” the then-minister for health said in 1961, while arguing for the closure of such institutions.
Community treatment
The idea was that community treatment could prevent people from getting seriously mentally ill, eliminating completely the need for secure units.
“Of course they never moved the resources to the community. They moved them elsewhere,” Kennedy says. Today no one wants to see a return of the old system but the uncomfortable truth is that some mental health sufferers need high-level, secure treatment to keep themselves and others safe, he says.
“Ireland has almost no intensive care wards at local level. If you are a young man with a mental illness and you are angry because of your mental illness you won’t be looked after locally. You’ll end up being arrested.
“And of course then they do something really, really serious like killing a member of their family, and then they have to come here for a very long time.”
The system means only the most extreme cases end up receiving secure treatment. There is no room for the other serious, but less extreme cases. These cases, left unaddressed, then become extreme cases.
“In the old days, which were only about 10 years ago, we admitted about 100 people a year. Most of them would spend a few months here and we would then divert them back to other services,” Kennedy says.
“Now most people aren’t able to get in because the beds are all full of people who have done much more serious things, people who need to spend much longer periods of time here.”
Campaigners argue that many young people in prison are there for minor crimes caused by their illness. A treatment environment would be much more suitable and more capable of stopping them reoffending.
Patients who come to the Central Mental Hospital from the criminal courts have usually pleaded not guilty by reason of insanity, or NGRI for short. The most typical patient is a man suffering from schizophrenia who has stopped taking his medication and has killed a family member – often a parent.
According to the most recent data available, of the 81 patients in the Central Mental Hospital sent there by the courts, 46 were charged with or convicted of a homicide offence. Serious assault and arson are the next most common offences.
A defence of NGRI is a difficult one and for that reason is used relatively sparingly. Under the Criminal Law (Insanity) Act 2006, an accused person must prove two things. The first part is quite easy: they must simply show they were suffering from a mental disorder.
The second part is much more difficult: they must show that the mental disorder was such that they either didn’t know what they were doing, didn’t know if it was right or wrong, or were unable to stop themselves from doing it.
Reason of insanity
A crime that requires any degree of planning would typically not qualify, even if the accused was mentally ill. And crucially, a crime committed as a direct result of taking drugs or alcohol would not qualify, even if the accused met all the other criteria set out in the act.
“If someone robs a bank, you can see there’s an element of planning,” says Greg Heylin, a senior civil servant who works with the Mental Health (Criminal Law) Review Board which decides if Central Mental Hospital patients are ready for release.
"Our position as psychiatrists is that we advise and the courts decide, and I think that's absolutely correct"
“They have to get cars together, they have to have an escape plan etc. It’s all quite methodical. But the things that you see the psychiatric patients doing, what is the aim? You just look at the act itself and you’ll see there is no purpose in what they’re doing. The vast majority are apprehended on the spot.”
A broadly typical case, although more gruesome than most, was that of Saverio Bellante, an Italian man who killed his landlord Tom O’Gorman at their home in Castleknock in Dublin in January 2014. Bellante, a schizophrenia sufferer, stabbed O’Gorman to death during a game of chess and then ate part of his landlord’s lung*.
A line from Bellante’s Garda interview illustrates his mental state at the time. “He wanted to stop my freedom. When playing there are common rules; he was acting for himself,” Bellante said of the chess match.
In 2015 Bellante was found not guilty by reason of insanity after the jury deliberated for less than two hours. He was sent to the CMH where he remains today.
Bellante’s trial followed the same pattern as other NGRI trials. Defendants are assessed by two psychiatrists, one for the prosecution and one for the defence, who inform the jury if they believe the accused was “insane” at the time of the offence.
A not guilty by reason of insanity offence is usually only used when there is a high likelihood of it succeeding. In fact, in the vast majority of cases the prosecution agrees with the defence that an insanity verdict is appropriate.
Research conducted by The Irish Times shows that of the 20 murder and attempted murder trials since 2014 where insanity was at issue, the prosecution accepted the NGRI defence in 19.
The only case in which the prosecution fought the insanity verdict was that of Tomas Gajowniczek, who attempted to kill his partner Alicja Kalinowska with a hammer. The DPP accepted he was psychotic at the time but argued his actions were brought on by anger and his cannabis consumption.
The jury agreed with the defence and returned a not guilty by reason of insanity verdict.
Retired High Court judge Iarfhlaith O’Neill is the chairman of the Review Board for the Central Mental Hospital. “It’s quite a hard defence to prove if you raise it,” he says. “If you don’t have the evidence to support it it’s not going to work.
“When they see the patients and how mentally ill they are, there’s usually little argument about it. Opinions tend to coincide.”
‘Logical verdict’
Trial judges usually reflect this in their instructions to jurors by telling them there is “only one logical verdict”. The jury then typically returns the not guilty by reason of insanity verdict after a short deliberation.
One judge, the late Mr Justice Paul Carney had a practice of not even letting the jurors leave the courtroom to deliberate before returning the verdict.
The not guilty by reason of insanity verdict plea replaced the old plea of “guilty but insane” which had a long list of problems. Many of these were addressed in the 2006 legislation. But the new law has its own issues; for one thing it failed to close a loophole which means potentially dangerous NGRI patients can flee abroad with no way for the authorities to extradite them back.
Heylin stresses the entire system is designed so this doesn’t happen, but it is not unheard of.
In 1988, John Gallagher was sent to the Central Mental Hospital after shooting dead his ex-girlfriend and her mother in Sligo.
He spent the next 12 years receiving treatment in the hospital, where he was gradually given more and more freedom in preparation for his release. By 2000, he was on unaccompanied work release one day and failed to return in the evening.
He fled to the UK where he was quickly arrested. However UK police couldn’t extradite him because under the Irish law he was not a convict. Gallagher later moved to Northern Ireland where he lived just a few miles across the Border from his victims’ family.
In 2012 he came south again and handed himself in to the Central Mental Hospital. The review board released him one month later after finding he was no longer criminally insane. According to legal observers there is nothing to stop a repeat of the Gallagher case under the current law.
Ciaran Lawless has a family member in the Central Mental Hospital. He says “carers” such as himself see the new system as “a wonderfully progressive and humane means of dealing with the most extreme mental-health challenges”.
But it’s by no means perfect. For one thing, there is no guarantee the jury will accept a not-guilty-by-reason-of-insanity plea even if told by a judge and two psychiatrists that an accused was insane under the Act.
This appears to be what happened in the case of Dariusz Alchimionek, who was convicted last year of manslaughter. The court heard Alchimionek believed terrorists were chasing him when his car crossed the road and collided with another vehicle, killing John Gorman (19) and critically injuring his brother, Adam (16).
The prosecution and the defence accepted he met the criteria laid out in the Act, and Judge Keenan Johnson told jurors “the only logical verdict” was not guilty by reason of insanity. Despite this, the jury convicted Alchimionek and he was jailed for six years.
“The jury’s verdict flew in the face of the expert medical evidence and as such is difficult to accept,” Judge Johnson said.
Accused and society
“The consequences of the guilty verdict in this case means that the court has no option but to send the accused – who was and is clearly suffering from a serious mental illness – to prison, despite the fact that a secure psychiatric stay would be in the best interests of the accused and society.”
Alchimionek is currently appealing the verdict.
Some have wondered why such cases need to go before a jury at all. Kennedy, who is often called upon to give psychiatric evidence for the prosecution in such cases, believes a jury system serves as a check on the doctors and lawyers involved.
“Our position as psychiatrists is that we advise and the courts decide, and I think that’s absolutely correct. I have a lot of faith in the courts system and the jury system as well. I think that’s quite a useful check and balance.”
Family members such as Lawless believe another issue with the NGRI system is that sufferers are only willing to use it for serious crimes like murder where a guilty verdict means a mandatory, indeterminate life sentence. There are two reasons for this, carers say.
One is that accused are often not lucid enough to enter an NGRI plea and instead insist they were perfectly sane at the time of the offence. This leads them to either fight the charge or plead guilty.
In theory, judges can’t accept pleas from people who don’t understand their consequences. However, according to Lawless, “it does frequently happen”.
“People who are known to be suffering from a major mental illness are allowed to plead guilty to a crime and are left to serve out a finite sentence in a prison. Once that term is ended, they must be released until such time as another event brings them into contact with the criminal justice system or the mental health services.”
This cycle leaves multiple casualties in its wake, including dead people. These could be avoided, says Lawless.
About 4 per cent of offenders are actually psychotic when sent to prison and suffer from either delusions or hallucinations. That’s not including prisoners with depression, autism or intellectual disabilities.
“When they’re picked up, the vast majority of them have been arrested for trivia like shouting in the street. Breaking in the windows in their parents’ home is a quite a common one. Breaching barring orders because the relationship has broken down and they’re despairing is also common,” says Kennedy.
Patients’ families
The CMH Carers’ Group, which is made up of patients’ families, agreed to contribute its thoughts for this article but members asked to remain anonymous.
The group’s facilitator points out that in prison, sufferers can’t be forced to take their medication, making a relapse almost inevitable. If this happens they can be temporarily transferred to the Central Mental Hospital but when their sentence is up they must be released which “brings them back to square one”, she said.
“Patients’ families find this very difficult to accept.”
When the system works well people are usually here a year before their trial. And it is quite impossible to deceive people if you've been observed 24/7 for a year"
The second reason sufferers are reluctant to used NGRI pleas is because prison terms for nearly all crimes, excluding homicide offences, tend to me much shorter than the average stay in the CMH.
“There are some people [in the CMH] who will never leave,” says Kennedy. “Now lawyers would jump on my bones for saying that. It’s not impossible for someone to leave. But there are some people who have been here for decades and they are likely to be here for much longer periods yet.”
Of those who are suitable for release, the average time spent in the hospital is “probably about 7½ years”, he says. Most prison sentences are much shorter than that. Last year, two patients were released from the CMH after serving about 17 years, roughly comparable to the average length of a life sentence.
A member of the carers’ group recalls one case where their relative’s legal team had advised the accused, who was unquestionably severely mentally ill, to plead guilty due to the likelihood of a short sentence.
“This showed a complete ignorance of what was in the best interest of the resident who had no means of accessing the forensic psychiatric care they needed should they plead guilty.”
“Fortunately” the accused eventually decided to plead NGRI and was sent to the Central Mental Hospital.
The problem can also arise with more serious offences. In 2014, Paul Henry was found not guilty by reason of insanity of murdering his mother and was sent to the Central Mental Hospital. He later successfully had the verdict quashed on appeal so he could plead guilty and be convicted of manslaughter. This would allow him to get a finite prison sentence rather than possibly spending the rest of his life in the CMH.
By the time of his retrial he changed his mind and again pleaded not guilty by reason of insanity. A jury accepted the verdict for a second time and he was sent back to the hospital.
Gaming the system
For those who care for the patients, one of the most frustrating "myths" surrounding the CMH is that sufferers are simply criminals who are feigning illness to get sent to a comfortable hospital instead of a dank prison cell, à la Jack Nicholson's character in the film version of One Flew Over the Cuckoo's Nest.
Asked if the system can be fooled, Kennedy takes a moment to think. “Well anybody can be fooled.
“But when the system works well people are usually here a year before their trial. And it is quite impossible to deceive people if you’ve been observed 24/7 for a year. We’re not able to do that at the moment because we’re not able to admit people in advance of their trials.”
"I would love the whole of the community to see what I see. Because I think it would change attitudes to mental health a great deal"
The pressure on the service means it is technically possible someone could fool the system before their trial, but Kennedy says it is not something he has seen. “The problem is actually that the prisons are full of far more people than we have that are severely mentally ill.”
O’Neill and Heylin on the review board are even more certain it can’t be done, partly because there is little incentive to do it. The CMH is a much more difficult place to get out of than prison. Last year just two out of 83 patients reviewed were released unconditionally. A further four were released under strict conditions and one of those was later recalled.
“The chances of gaming the system are extremely remote. When you see people coming to the hospital first they are all extremely ill, they are very psychotic,” O’Neill says.
On arrival patients often have to be kept in seclusion while doctors formulate a drug regime to end their psychosis, a process that can take up to a year.
“To see them at that stage coming up to the first tribunal, there is no gaming there. They are incapable of gaming, a lot of them are incapable of thinking,” he says.
The psychiatrists also have a specific “gaming” test, according to Heylin, which assesses the patients’ veracity.
In fact, those sent to the CMH from prison are usually very eager to return to prison. “It’s extraordinary. The majority ask the board to send them back, even when the board says it will be very dangerous for them to be in prison,” says Heylin.
Many want to go back because, unlike prison, there’s no access to illicit drugs in the Central Mental Hospital, O’Neill says.
‘Freedom’ of jail
“There’s also a certain element of freedom in prison,” says Heylin. “the observation levels in the hospital are very high; they have to be. Whereas in prison you get up in the morning and if you don’t cause trouble the prison officer is going to count you but he’s not going to be on your case.”
The vast majority of patients suffer from life-long illnesses. The most common by far are schizophrenia and schizo-affective disorders but in recent years there has been an increase in patients with autism spectrum disorder and other intellectual disabilities – to the extent the hospital has established a specialised treatment unit for them, beside its gym and disused swimming pool.
Psychopathy, the disorder the public most commonly associated with murder, is not a mental illness under the Act, as psychopaths know what they are doing is wrong and can stop themselves if they want to.
In fact, Kennedy has his doubts about whether it’s a real condition at all. “Psychopathy is a sort of historical artefact. It’s essentially a list of pejorative adjectives for describing people while not using moral terms like ‘bad person’. It’s an academic debate that goes on and on.”
In dealing with people with chronic disorders like severe schizophrenia, there is always a risk in releasing them that they will commit more violence, O’Neill says.
This is mitigated by the incremental process of release. During their time in the CMH, patients progress from the high-security ward to the medium-security ward and then on to Laurel Lodge, a open ward on the grounds of the hospital.
While there they start making trips outside the grounds in the company of nurses. The length of these trips increases over time until they are granted day release, a process which can take a few years. “When someone gets to the point of discharge they have usually been well for a long time,” says O’Neill.
After that, if somebody breaches the conditions of their discharge, Kennedy can have them recalled – with the assistance of An Garda if necessary. Often it is the patient who will refer themselves back.
“If they’ve got enough insight they’ll say: ‘I’m going crazy again. It’s coming back and I can’t control it. I need help’,” says Heylin.
This word “insight” comes up again and again. If a patient doesn’t have insight into their condition and what they have done, they are not going anywhere.
"One of the things that really affected me is how normal psychiatric patients are. They are normal human beings who have a terrible illness"
Role of insight
“Everything is about getting to this thing, insight,” says O’Neill. “First, that these awful things in their head aren’t real. Second, that they have an illness and third that it can be managed by treatment. And once a patient comes to that point you’ll find that the treatment and the rehabilitation starts to really motor.”
Families are crucial to this process, even in cases where the patient has murdered a family member. According to Kennedy, Irish society has a unique advantage in this regard.
“I practised for 19 years in the UK where I [worked in a very similar capacity]. The big difference in Ireland is the extent to which families very quickly reconcile with their family member. It’s a really, really positive aspect of working in Ireland that patients aren’t usually alienated from their families. They are a large part of the recovery for our patients.”
In many cases it will be a family member who pursued a criminal case against the patient because that was the best way of getting them effective, secure treatment.
In 2012 former Labour MEP Proinsias De Rossa gave evidence against his son that he thought he was going to die at his hands during a vicious assault. Fearghal De Rossa was found not guilty by reason of insanity and sent to the CMH where he remains. At the conclusion of the case, De Rossa snr said the only reason he had pursued the prosecution of his son was to get him to submit to psychiatric treatment.
“Many of those who walk through the gates of the CMH for the first time are traumatised and in a state of shock,” said one relative of a CMH patient. “But, it can be a relief for some who have struggled with getting their relative secure care for many years.”
Despite the Victorian conditions of the hospital and the loopholes of the NGRI regime, families and staff members say there are many positive aspects of the Irish system.
The introduction of the not guilty by reason of insanity verdict in 2006 “brought much-needed common sense” to the area, says Lawless and grants a level of care not present in the rest of the mental health system.
“It means that they will be provided with a very thorough and complete care plan and may be recalled to the hospital at any time if there are concerns about their mental health or compliance with medications. This level of medical care is not available anywhere else within the service.”
Terrible illness
For the professionals like Kennedy, the severity of the cases means the hospital has become a “centre of excellence” for dealing with mental health, especially in the area of research.
Many newly qualified mental health workers spend a year or two in the hospital and they leave with a level of expertise and confidence that filters down through the whole service, he says. “They gain the ability to recognise severe problems and the confidence to know they can cope with those problems before they get more severe.”
For O’Neill, one of the best parts of his job is seeing a patient progress and get a handle on their illness.
“One of the things that really affected me is how normal psychiatric patients are. They are normal human beings who have a terrible illness. When you get to know them, as I get to know most of them, I feel there’s a bond. There’s certainly a lot of empathy there.
“I would love the whole of the community to see what I see. Because I think it would change attitudes to mental health a great deal.”
*This article was amended on July 19th, 2018
