System failed architect who killed mother

A successful architect who suffered a breakdown and stabbed his mother to death before killing himself was a victim of grave failings in the emergency mental health care system, an independent inquiry has found.

In one of the most highly critical reports of the care of the dangerously mentally ill to appear in recent years, the inquiry says the efforts of 14 doctors, nurses and social workers over one weekend in January 1996 failed to protect Gilbert Kopernik-Steckel, 33, and his family, of South Norwood, south London, from the effects of his acute psychotic illness. Although all the professionals recognised the danger he posed there was "an overwhelming failure in communications" which led to the deaths, it says. A consultant psychiatrist who visited the family at home described the mother, Suzanne, 57 as "a sitting duck".

A separate inquiry, also published yesterday, into the death of psychiatric patient David Howell of Birmingham identified similar failings in his care, although it says changes it recommends would not necessarily prevent a similar incident in the future because of the unpredictable nature of psychotic illness. Unlike Mr Kopernik-Steckel, Mr Howell had been a long term mental patient who had lived in a residential home since 1985 and who was stable and compliant but whose condition also deteriorated suddenly and without warning. On 20 November last year he was shot dead by police after taking a supermarket manager hostage by holding a knife to his throat.

Both inquiry reports add to the litany of disasters involving the care of the mentally ill which have repeatedly highlighted poor communication, inadequate co-operation and a lack of mutual respect among the agencies involved.

Mr Kopernik-Steckel's case was unusual because he had no known history of mental illness. He was a middle class professional man pursuing a successful career in Paris and Berlin who had returned home to spend Christmas with his family when his illness struck. Over the last, fateful weekend, he twice admitted himself to the local mental hospital but twice discharged himself, despite instructions from medical staff that he was to be detained which were not communicated to the nursing staff who let him go. It was the failure of the Croydon Mental Health Unit to keep him in hospital during the emergency that attracts the inquiry panel's strongest criticism. "We do not believe that the seriousness of this incident could have been predicted. We do, however, believe that the tragic outcome was not inevitable," the report says.