Extract from THE MIND OF A MURDERER by Dr Richard Taylor

Chapter 11

 

Mothers who eliminate an unwanted child may have no psychiatric disorder other than an abnormal personality, but there can be a history of family discord and maltreatment. The first murder case of any type that I encountered in psychiatry was Stella North, an isolated woman in her early twenties
who had been transferred to secure hospital facing a charge of murder of her newborn baby. When I joined the team, she was halfway through a three-
month in-depth psychiatric assessment. A report was being prepared to assist the CPS in their decision as to whether the murder charge (with a mandatory life sentence) would be replaced by one of infanticide (where all sentencing options would be open, including a hospital order under section or even a non- custodial penalty such as probation).

 

In my inexperience, I thought it obvious that, as this was a case of a mother killing a newborn baby, ‘the balance of her mind must have been disturbed’ – still the legal criteria for infanticide.

 

I probably had my aunt’s history in mind when I made that simple assumption. But forensic psychiatry is a field where you must assume nothing.

Stella’s case had been discussed in our weekly seminar with a forensic psychotherapist. To understand murder, you have to come at it from different directions. A psychotherapist trained in psychoanalytic theory can give us a different perspective.

 

I went into the fortnightly seminar clutching my notes, ready to present the case to Calista, the psychoanalyst assigned to our team. She told me to put away my notes and instead describe Stella’s story to the seminar, as well as what it was like to be in a room with her. I laid out the background, from
memory, and noted that Stella seemed to be detached from the killing and from her dead baby. The discussion went on to consider not just her disturbed mental state but also her murderousness to her unwanted baby. Stella had concealed her aggression by seemingly separating herself from her
actions. She seemed disconnected from any feelings towards the dead baby, as if it had never existed in the first place.

 

The debate about Stella forced me to re-think my simplistic ‘mental illness’ model of infanticide. It gave me an uncomfortable thought, too. My cousin Louisa had been an unplanned arrival. She was also a difficult baby who didn’t settle. Although there was no doubt that Georgina had been affected by her grossly disturbed mental state, had she possessed a degree of murderousness towards Louisa? At this point, I’d not heard Georgina’s account of the smothering, which I now know had been a response to incessant crying, albeit in a highly disturbed mental state. Stella’s was the first case of infanticide I had seen professionally, and that must have been when I began reflecting properly on Georgina’s story, which in turn set me on the journey of enquiry that ultimately led me to my work at Holloway.

 

Further details revealed in Stella’s case suggested a level of ‘murderousness’ that was hard to fully reconcile with infanticide. She had telephoned the police from her fourth-floor council block flat, reporting her baby missing. Police officers were all over it: dozens of uniformed staff searched the area,
doing house-to-house enquiries and seizing CCTV evidence. After a twenty-four-hour search, the cold, dead body of her newborn was found in the large communal waste disposal bin at the bottom of a rubbish chute, which originated outside the door of her flat.

 

You can imagine the outrage of the police officers who’d conducted this search, believing it to be abduction, only to find that the mother had disposed of the baby herself. She was not psychotic, but the pregnancy had been unplanned and unwanted – she was immature and isolated and suffering
from post-natal depression.

 

A few years later, I coincidentally found myself as a newly qualified consultant (in an ‘acting up’ or locum post) supervising Stella in outpatients. After a year in secure hospital, she had been given a non- custodial penalty and made subject to probation supervision with a condition of psychiatric treatment.
But she seemed blithely unconcerned about what she had done (dissociated, in psychiatric terminology), often arrived late and frequently cancelled appointments.

 

She was in a new relationship and thinking about starting a family, despite what had happened to her first baby. If she did go ahead with her plans for another baby, a child protection team would be keeping a watchful eye on her with a pre-birth case conference. They would have to answer difficult questions. Could Stella be safely allowed to care for another child? Would it be safe to even allow her to hold the baby for a few minutes after birth? These were questions I later faced myself while managing pregnant women with serious mental disorders – what we call perinatal psychiatry.

Children killed by parents or carers as an extension of child abuse was a hot topic in the media while I was at Holloway, with the deaths of Victoria Climbié and Baby P in north London attracting blanket media attention. The publicity around those cases focused almost exclusively on the perceived
failures of social services and seemed to ignore the culpability of the parents (another example of our contemporary blame culture). I have seen so many cases of criminal neglect leading to death and deliberate lethal abuse, but a couple of examples linger in my memory.

 

In Holloway I was asked to see Amelia Stevenson, who had been remanded there having been charged with murder. She herself was a modern-day
foundling, abandoned at birth and found in a plastic bag on the doorstep of a hospital before going on to short-term foster placements and a children’s home.

 

She displayed disturbed behaviour at school, dropped out of education and progressed through recreational illicit drug use to heroin addiction. She had several unplanned pregnancies and her first baby died within a few weeks from pneumonia. Her second had been made subject to a full care order by social services and was in the process of being permanently adopted.

 

Amelia went back to injecting heroin – ‘if you can’t beat them, join them’, she said – and then became pregnant again by her boyfriend, Seth.

During this third pregnancy, social services agreed – oddly, you might well think – that there would be a trial of her parenting with extensive support. She had consented to stay off heroin during the pregnancy so as not to pass her dependence on to the baby. But she quickly relapsed, and managed to hide
this from the midwives and social workers (by using ‘street’ methadone and later switching back to heroin).

 

When the baby, James, was born, Amelia could see that he was ‘very sick’, but only she knew that he had heroin withdrawal, which produces flu-like
symptoms: muscle pain, fever and chills. The distressed baby was crying frequently. ‘Instead of getting professional help, we thought we could manage it ourselves . . . we thought that if we proved we could look after him, they might let us keep him. Joe got some methadone . . . we gave it to him with his feed and he seemed to get better . . . The midwives and health visitors were coming around daily, but we managed to conceal it.’

 

One day Amelia woke late, feeling groggy from the warm blanket of heroin oblivion. The next morning, he was still in bed . . . I had a feeling; I knew something was wrong . . . my boyfriend cried and said, “Amelia, he’s dead.” I thought he was still asleep, but he was cold. I tried to feed him, but his body was already stiff.’

 

Manslaughter – five years’ imprisonment.

 

Despite significant self-harm, Amelia was turned down for a psychiatric hospital bed, her negligent homicide not eliciting much sympathy.

In Amelia’s case, her neglect of James was hidden from health professionals. This concealment of negligence or abusive behaviour towards children is not uncommon and can take many forms, as I discovered early in my medical career. By chance, while working on the chest medicine team at the
Mayday Hospital, I encountered some unusual psychiatric cases which have stuck in my mind to this day. During those six months there, it had been hard enough keeping up with the torrent of referrals from A & E, chasing blood results and replacing blocked intravenous drips. At that time, I probably came the closest to throwing in the towel and walking away from medicine altogether. Yes, it was that bad, even after six years of training. Despite our exhaustion, we had to stay alert, as the sickest patients were fighting for their lives – and sometimes losing them. But among those genuine patients, we would detect a few who were faking a medical problem. We presumed they were doing so in order to gain the attention that goes with a hospital admission, or  maybe to get a kick out of tricking us and wasting our time.

 

But what motivates someone to fake the painful colic of a kidney stone, even surreptitiously cutting a fingertip to drop blood in a urine sample to further convince us?

 

This was more than just seeking painkillers, as we’d switched away from drugs with abuse potential. Once discovered, these patients would be summarily admonished and banished from the hospital, without so much as an opinion from the ‘trick-cyclist’ (semi- affectionate, yet denigratory term for my future profession, used by the physicians and surgeons).

 

One particular case in this group caught my interest. A young woman, Tamara Atkinson, had been admitted to the medical ward, suffering with poorly controlled epilepsy. She’d been accused of poisoning her own child with her anti-epileptic medication and then presenting the child to the doctor with
unexplained symptoms. When the child had been admitted to a paediatric ward for observation, Tamara had tampered with the drip, causing a life-threatening infection by contamination of the infusion, and putting her child in intensive care. Next Tamara suffered an apparent seizure in police custody and was transferred to the Mayday emergency room.

 

Admitted to the ward, she continued to have uncontrolled fits despite adequate treatment and we hastily ordered brain scans and a brain wave test (electroencephalogram), worried she might have a growing brain tumour. When these tests were all negative, we became suspicious. I observed her having a seizure in her hospital bed. It looked convincing, with rhythmic contractions, her head arching back. She even went to the trouble of wetting the bed, which commonly happens in genuine fits.

 

While we set about confirming these were fake ‘pseudoseizures’, Tamara started to develop multiple large, infected, pus-filled boils on her legs and her left arm. The child abuse investigation receded into the background as we became concerned that there was something wrong with her immune
system. We checked her blood for HIV and ran a full panel of standard blood tests and microbiology swabs, looking for an unexplained infection. After a search in the literature for rare and unusual conditions, a possible candidate jumped off the page, namely ‘Job’s Syndrome’. Named after the biblical
figure, this was a dysfunction of the white blood cells that usually fight infection and can lead to uncontrolled pustule formation. It seemed to fit the bill, so we booked Tamara in for a test at a neighbouring specialist hospital.

 

Meanwhile, our consultant had been called to give evidence in court about Tamara’s medical status and whether she wasfit to attend the criminal and family court proceedings. While we were trying to unravel all of this, a hospital porter came upto me one day and in a conspiratorial whisper, said, ‘Doc, I
don’t mean to interfere, but I just saw something I thought you might want to know about. You know that lady in bed seven? I just saw her sticking needles in her leg.’

 

It transpired that Tamara had been contaminating needles with her own faeces and sticking them into her skin to produce the boils. She had both Munchausen syndrome and Munchausen by proxy (the deliberate fabrication in yourself, and inducement in a vulnerable other, of a ‘factitious’ medical
condition). Tamara clearly had a significant personality disturbance, and she would have to go to court and face her accusers after all.

 

Fascinated by the process of unpicking the mental gymnastics that must have been required in order to think and behave like Tamara, I presented her case, complete with slides of the offending lesions, at our monthly medical grand round. Afterwards I was taken aback when the senior dermatologist
said to me, ‘All very interesting, but next time bring us a real rash.’

 

I was realising at this early stage that I’d have to find a branch of medicine which was more than skin-deep. Psychiatry was reeling me in.

 

To me, Tamara’s affliction was a very real rash. Other skin rashes may reveal underlying medical conditions like scabies, syphilis or systemic lupus erythematosus an autoimmune disease with a characteristic facial rash). Hers was an open window into her highly disturbed personality: an example of a woman turning her aggression on her own body and reproductive system, namely her child – the process that has been described by Welldon.

 

The condition, or pattern of behaviour, known as Munchausen by proxy constitutes a severe form of child abuse, and is usually a criminal offence. It is generally found in women who are the mother, carer or nurse of the child. They present the child to doctors with an apparent illness, which is later discovered to have been induced by the caregiver through false reporting of symptoms, or by inflicting injuries on or poisoning the child.

 

Controversial medical research involving covert surveillance has even found that some mothers of children with breathing problems were actually smothering their own babies. The videos are striking to watch. Mothers can be seen clearly and repeatedly trying to suffocate their own child, while presenting this as a spontaneous cessation of breathing (an apnoea attack). The babies are wired up to breathing and heart monitors and nurses are watching on camera, ready to come in and prevent the worst. This research suggests that, while the vast majority of cot deaths are genuine and devastating, a very small proportion are likely to represent concealed infanticide if the smothering is not detected soon enough.

 

Despite the evidence, there has been a reluctance to accept that mothers are capable of this twisted combination of deception and harm. Does the deception allow these mothers to deny their aggressive impulse to the child and also feel exultant as they trick the doctors, thus assuaging their own feelings of helplessness?

 

This is one attempt at a ‘psychological formulation’ but the mechanisms remain largely unanswered. These mothers often show signs of severe abuse or neglect, self-harm or eating disorders, and may have presented with unexplained symptoms and/or had unnecessary hospital admissions and
operations themselves.

 

They also have difficulty vocalising their distress, something we psychiatrists call ‘alexithymia’, loosely translated as ‘the absence of the words to describe a state of mind’.

 

The experience I had gained as a junior medic, including cases like Tamara’s, helped me later understand some of the child abuse cases I saw as a psychiatrist at Holloway prison. So I had learned that killings of children as an extension of abuse and neglect come in many guises, and the abuse which
precedes the killing can be concealed. But sometimes there are cultural and religious practices towards children that may be condoned or even encouraged in other societies, but which constitute criminal offences in the UK, and which, in extremis, can lead to fatalities. Female genital mutilation (FGM) – which affects 200 million women and girls around the world, according to the Five Foundation – is an example of this. In the UK it is illegal, with
the acceptance now (at least by parliament) that misguided cultural sensitivities must be put to one side in order to protect young girls from irreversible harm caused by this culturally sanctioned abuse. In a similar way, other physical and emotional abuse which is practised in some communities – in the context of beliefs about voodoo, the occult and demonic possession – must be called out and made subject to criminal sanctions.

 

But from my point of view as a forensic psychiatrist, these practices need to be distinguished from delusions. Delusions may respond to psychiatric treatment, whereas culturally normative beliefs about witchcraft will not. Non-psychotic ideas about the malevolent forces of evil spirits or witchcraft
are surprisingly common, especially in a culturally diverse city like London. For example, beliefs about ‘djinn’ (or genies) are common in some Islamic communities and ‘evil spirits’ or ‘demons’ are often referred to by those from sub-Saharan African countries.

 

Studies which have surveyed religious and cultural attitudes in different countries have found that beliefs about the existence of evil spirits are held by fifteen per cent of Ugandans and up to ninety-five per cent of the population of Ivory Coast. Cultural beliefs about demonic possession have resulted in significant violence to children, with accounts describing exorcism procedures involving chilli pepper being put in children’s eyes, beatings and even
ritual murders, particularly of albino children, whose body parts are said to possess special powers.

 

In 2008, more than 300 cases of murder and disappearances linked to ritual ceremonies were reported to the police in Uganda. The Ugandan government appointed a special police taskforce on human sacrifice, as there were several high-profile arrests of parents and relatives accused of selling
their children to witch doctors for ritual sacrifice, to guarantee wealth and prosperity.

 

Of course, London is no stranger to the ritual murder of children. In 2001 the case of ‘Adam’ involved the discovery of an unknown boy’s torso in the Thames. Following a complex investigation, he is now thought to have been trafficked from Benin City, Nigeria, via Germany to the UK. He had been
poisoned (sand flecked with gold particles was found in his stomach), as well as bled and skilfully dismembered, most likely as part of a ‘muti’ or ‘voodoo’ ritual murder.

 

In Holloway prison, I saw other examples of culturally sanctioned violence towards children. In one particularly distressing case, a young Mauritian woman who was in a relationship with a West African man had been persuaded by her partner that their six-year-old daughter was possessed by
evil spirits. The couple had beaten her repeatedly, burned her with hot candles and then stitched her into a sack, planning to throw her into the canal near Kingsland Road. Luckily, they were disturbed by a neighbour and didn’t follow through with their murderous plan. It was only when their daughter appeared to be tearful and dishevelled at school that teachers made a referral to social services and the full story emerged. Although her partner had clearly influenced her, the mother showed no evidence of mental illness – she was dealt the full force of the law and received a substantial prison sentence.

 

Despite the disturbing details of all this violence towards children, I found that by this stage of my career I was able to focus on unpicking the clinical and forensic evidence of murder cases without being too distracted by the nature of the material. It is said that it takes around five years to settle in as
a consultant in most medical specialities, which I think is about right. Over time, I found my forensic anxiety had diminished. I’d also learned to manage my stress levels by not accepting every referral or teaching invitation, trying not to be omnipotent in preventing every psychotic crime in my patch, and protecting my time at weekends with a ban on report-writing on Saturdays.

 

Perhaps forensic psychiatry had become, for the most part, just another profession for me, inured to violence and its consequences. Some people go to work to look at a trading screen, design buildings, teach a classroom of children or read manuscripts, but a few of us traipse around the prisons to interview murderers and try to make sense of them.

 

When asked, ‘What do you do?’ at social occasions, I’d just say, ‘I’m an NHS hospital medic,’ in order to avoid the inevitable discussion about the meaning of evil: ‘Surely all killers must be crazy?’ or ‘Why can’t we just hang them all?’