The Guardian, December 2004

In the second part of his investigation into mentally-disordered prisoners, Nick Davies tells the story of a prisoner who has become a living nightmare, one of the several thousand severely ill held behind bars and denied a hospital bed.

We do not need to know exactly what happened to Glenn Wright when he was a child. It is enough to say that he suffered most painfully at the hands of an adult who forced him to live through nightmares. Before that, he was just an ordinary boy, growing up in Northampton in the 1970s, his father a supervisor at the Carlsberg brewery, his mother looking after the five children, of whom he was the youngest. Afterwards, he was himself a nightmare in the making.

Glenn Wright is not at all well-known to the outside world, but inside the prison system, he is notorious, and he is sometimes described by governors as the most difficult prisoner in the country. Even from a maximum security cell, he exerts enormous power over those around him. He does this most often by attacking his own body as a form of blackmail. He swallows razor blades and screws. He eats batteries. For years, he has kept open a savage wound in his leg; sometimes he puts his own shit into it. He pushes taps and broken porcelain into his rectum. He went through a phase of keeping a cup of blood in his cell to throw at anybody who tried to come too close.

Occasionally, in his campaign to control those he comes into contact with, he embroils others in his theatre of horror. He told a prison pyschiatrist that he would like to kill her, slice her, fry her and eat her. He has talked about murdering people and feeding them to dogs or to their own families. He has killed other prisoners without touching them: he talked three of them into hanging themselves; one recovered, and two of them died, and he was given life for murder and aiding suicide.

For the psychiatrists who have examined him, Glenn Paul Wright, now aged 32, is suffering from a severe personality disorder, the legacy of the relentless torment which he suffered as a child. The disorder pitched him into a life of offending, he ended up in prison, where he remains trapped in a regime which cannot treat him effectively. He is locked up alone for 23 hours a day. If he leaves his cell, he has both hands ratchet-cuffed to a prison officer with four others in escort; he has the option of exercise in a fenced cage. There have been times when, as a deliberate policy, he has been denied all access to psychiatric care. Routinely, he has been shifted from one high-security prison to another, even though prison psychiatrists have warned that this aggravates his condition.

The one solution to the problem - both for Wright and for the prison service - is that he might be tranferred to a high-security hospital for treatment. Five different forensic psychiatrists have assessed Wright and recommended that he be moved to a secure psychiatric bed. And yet, he remains in prison.

It is government policy that all patients be given "timely access to an appropriate bed". And that specifically includes prisoners. That policy is wrecked. There are thousands of severely mentally-disordered prisoners who are being denied transfer to outside hospitals. When the chief inspector of prisons' medical expert studied a sample of inmates in local prison hospital wings two years ago, he found 40% of them were not just mentally ill, but so ill that they should have been sectioned under the Mental Health Act.

The problem is two-fold: first, that the Department of Health has failed consistently to provide anything like enough secure psychiatric beds; and second, that many NHS psychiatrists simply do not want disruptive patients on their wards. Even the new units which the government has created for the most dangerous prisoners with severe personality disorders have refused to take Glenn Wright.

Dr Adrian Grounds, a forensic psychiatrist who works in prisons and who is also a senior lecturer at the Institute of Criminology at Cambridge University, estimates that there may be up to 3,700 prisoners who are so severely mentally disordered that they should be in a psychiatric hospital but for whom there is no bed. And where beds are available, delays are commonplace, and prisons are replete with stories of hospital psychiatrists ducking and weaving to avoid taking the most difficult prisoners.

One of the most senior forensic psychiatrists in the country told us: "Psychiatric teams come into prisons and make the most amazing judgments. I had a man in custody who was grossly manic, naked, occasionally smearing himself in his faeces and spending 22 hours a day in seclusion. He needed to be in a safe environment. But the visiting psychiatric team said: 'No, no, you're doing very well with him, he's fine here.'"

Glenn Wright drifted easily from a boyhood of pain to an adolescence of crime. By the time he was eleven, he was regularly truanting from primary school. By the time he was 13, he was expelled from secondary school and appearing in court for burglary and theft. He was recommended for a special school; it never happened. By the time he was 15, he was sniffing glue, smoking dope, swallowing blackmarket pills and serving his first sentence at Glen Parva Young Offenders Institute. He told psychiatrists he was hearing voices; nothing was done. When he was 19, he served his third sentence at Glen Parva. Since then - a period of 13 years - he has spent all but seven months in jail and has little prospect of release.

At the beginning of those 13 years, he was just another mentally-disordered offender. In Glen Parva, he was beaten up by other prisoners and swallowed some razor blades. He was transferred to Feltham, where he cut himself and was put on the hospital wing. The doctors said he had an anti-social personality disorder with impulsive acts of deliberate self-harm in the context of abnormal personality traits. He took to slashing his arms, cutting his wrists and swallowing more razor blades.

A couple of times, he was released, utterly unchanged in his behaviour. Rapidly, each time, he went back inside. The last time was in June 1996 when, aged 24, he was given three years for burglary. At the police station, he slashed his wrists. A few months later, he reported being assaulted and seriously harmed by other prisoners at Woodhill. Now, his self-harm started to take off: he swallowed screws, smashed up his cell, strangled himself, removed the tap from his cell sink and buried it in his rectum, tore a deep wound in his leg, ripped bits of fixtures and fittings from the cell walls and inserted them into his leg wound. Then his behaviour spilled over onto those around him.

On November 16 1996, a few weeks after he reported being seriously assaulted, he persuaded his cell mate at Woodhill, William Scott, to hang himself. On February 8 1997, still in Woodhill, he persuaded another cell mate, Peter Karelius Smith, to do the same. On January 27 1998, in Pentonville Prison, he persuaded Kenneth Cross to swallow an overdose of tablets and hang himself with a torn sheet; the noose broke, and Cross survived. As a result of what Cross told the authorities, Wright was prosecuted for the incidents with all three cell mates.

Thus far, there was no sign at any time of the prison service providing any effective treatment for his disorder, which was clearly becoming worse. That is not unusual: as we described yesterday, the mental disorders of prisoners were ignored for years; and even now, when the prison service has started to tackle the problem, treatment in prison remains deeply inadequate. And even those with the most serious disorders - those who would be sectioned and sent to secure hospitals immediately if they were in the community - are trapped in a system that cannot help them.

The chief inspector of prisons, Anne Owers, personally came across a man who was strapped into a body belt with his wrists clamped to his waist. When she asked about him, she was horrified to be told that he was kept like that permanently: it was the only thing the prison could do to stop him castrating himelf. One of her inspectors witnessed a prisoner gouging out his own eye ball - he had started on the other eye before officers managed to restrain him.

With their move to an outside hospital either blocked or delayed, the condition of many severely disordered prisoners deteriorates. The Prison Service is currently being sued by the family of a man who was stored on a hospital wing, awaiting a long slow transfer, and who tried to kill himself by hanging. He failed and, a week later, he tried again. Once more he failed. Two weeks later, he tried a third time and, by the time he was discovered and saved, he had been hanging long enough to suffer apparently permanent brain damage.

When he was charged with murdering his two cell-mates and attempting to murder a third, Glenn Wright finally forced the system to confront his condition. In the run-up to his trial, he was visited in prison and assessed by two independent forensic psychiatrists. Both agreed that he now had a serious psychopathic disorder and that he met the criteria for admission to a special hospital. On April 30 1999, Wright was given a life sentence at the Old Bailey and waited to be transferred to a secure psychiatric bed.

A year later, he was still in prison, untreated, still attacking his body and now covering himself and his cell in his own dirt. He waited like that for two years before finally, on November 7 2000, he was moved to Broadmoor.

The government says it has introduced "quicker and more effective arrangements for transferring the most seriously ill prisoners to appropriate NHS facilities" and claims that, on average, at any one time there are only 40 prisoners waiting longer than the official target of three months to be transferred to a secure mental hospital. The truth is more complicated than that. First, any patient in the community who was considered so mentally disordered that they had to be sectioned would be moved to a psychiatric bed within hours. A delay of a week would be extraordinary, and so a target of three months is scarcely effective.

Second, the government is dealing in averages, which disguise the long delay experienced by some prisoners. And the disguise appears to be deliberate. The Department of Health are refusing to release the true figures even though they have them and even though they relate to a government target for which they are accountable to the public. We spent more than two months asking for them: the department finally replied by claiming that the figures are "management information, not routinely published".

Third, prison staff report that outside doctors will fiddle the system by stalling their assessment until they have a bed available so that the true length of the delay is disguised. Finally, psychiatrists who work in prisons tell us that the process of asking for a transfer is so time-consuming and so unlikely to succeed that they begin it only for the most extreme cases, leaving a long queue of severely mentally-disordered prisoners who ought to be transferred but who do not even get to the starting line (or show up in the government's statistics).

There is a man in a Midlands prison now, for example, who is below average intelligence, diagnosed psychotic and hearing voices, frequently cutting himself, his condition exacerbated by being held in prison. The consultant psychiatrist who works part-time at the prison says he should be in hospital, but he is not dangerous enough for a high-security bed, not sick enough for a medium-security bed and too likely to abscond for a bed on a local locked ward.

The Department of Health's refusal to provide enough secure pyschiatric beds is like a boulder in the doorway that should lead the very ill from prison to hospital (just as their failure to provide effective community treatment diverts so many of them to prison in the first place). This summer, Dr Adrian Grounds of the Institute of Criminology told a Cambridge conference that the shortage of secure beds was so grave that: "Overall, the picture was of a system that was under such pressure that it was almost seized up."

Dr Grounds referred back to research in the early 1990s by professors John Gunn and Tony Maden, who analysed samples of prisoners to discover how many were in clinical need of transfer to an NHS psychiatric bed. Acknowledging that this was "fraught with difficulties and uncertainties", Dr Grounds applied their findings to today's much larger prison population and concluded that there may now be up to 3,660 men and woman who are so severely ill that they should be in a psychiatric ward but who are trapped in prison for want of a bed. Most of these men and women will not even have been assesed for transfer. Of those who are, we are told that at the moment there are some 300 men and women who have actually been sectioned but are still stuck in prison cells. Dr Grounds said: "The policy aim of diverting the mentally disordered from prison to the care of health and social services has chronically failed."

The Department of Health refused to comment on Dr Grounds' findings even though we gave them three months to do so. They said it was no longer their job to provide secure beds - it was a matter for the local health trusts. If Dr Grounds is right, up to 3,700 prisoners are blocked from appropriate beds - and yet, according to the latest available figures, in 2002/3 we transferred only 219 sentenced prisoners to psychiatric hospitals - and 45% of them (99) were sent back again. Which is what happened to Glenn Wright after he finally made it to Broadmoor in November 2000.

He lasted only four months. During that time, he threatened staff, incited other patients to refuse their medication and was put into seclusion where he tore panels from the wall and covered himself in faeces. The doctors at Broadmoor did not dispute the diagnosis which had brought him there but told the Home Office that he could not be managed safely in their high-security hospital. In March 2001, he was taken back to prison.

Over the following twelve months, he was shuttled from one high-security unit to another. This is a strategy which is known among prison governors as 'sale or return': when a prisoner is difficult, the governor ships him off to another prison on the understanding that, if he acts up there too, the second prison can send him back. The inspector of prisons, Anne Owers, earlier this year told the parliamentary joint committee on human rights: "You have a whole category of prisoners who are basically on a merry-go-round. That is likely, I would have thought, to exacerbate their mental condition." She said she knew of one prisoner who had been transferred 30 times in two years and who was now dead. After he was removed from Broadmoor, Glenn Wright was moved seven times in twelve months from one maximum-security unit to another, finally bouncing from Long Lartin to Woodhill, back to Long Lartin, then back to Woodhill again.

His attacks on himself became frantic. In Full Sutton, he swallowed three batteries and was taken to general hospital to have them removed. In Whitemoor, he cut his arms and covered himself in shit. In Long Lartin, he kept a razor blade under his foreskin and put a tap up his backside. In Woodhill, he buried a pen and more shit in the open wound in his leg and put another tap up inside him. En route to one of his stays in Long Lartin, he produced a razor blade, cut up his clothes to make a noose and started strangling himself. When he finally arrived at the prison, he produced another blade, made deep cuts in his arms and legs and refused to have them treated. While this was going on, the Home Office and Rampton high-security hospital refused even to assess him and said he could have hospital treatment only if he improved his behaviour.

It is not just the shortage of beds which keeps mentally-disordered prisoners out of secure hospitals. There is clear evidence that the NHS discriminates against them. In the ten years between 1992 and 2002, the number of men and women sectioned to secure beds increased by 24% - but the number sectioned from the courts and the prisons fell by 24% (and this was while the prison population was rocketing). As the Department of Health itself admitted in a policy paper three years ago: "In some cases, it seems that the NHS does not always give a prisoner patient the same level of priority as they would have in the community."

At its worst, this sees NHS psychiatrists occasionally resorting to apparently cynical misdiagnosis to justify rejecting difficult patients. The mental health group MIND told the parliamentary joint committee on human rights in January of a mentally-ill woman who succeeded in being transferred from prison: "She got into the ward and was apparently more trouble than the ward anticipated, so she was hastily reclassified as having an untreatable personality disorder and booted out that same night. One wonders whether this was on medical or management grounds."

There is clear evidence that, under pressure of a gross shortage of places, hospital doctors may cherrypick the easiest patients. Researchers in 1998 studied 44 women from Holloway prison who had been referred to secure hospitals. Half were turned down, and the researchers found that, compared to those who were allowed to have beds, the rejected women were more likely to have harmed themselves, to have suffered childhood abuse, to have committed serious offences and to be seen as violent or dangerous. The research concluded that their rejection was the result not simply of difficulties in treating them but also of "inadequate service provision".

Further evidence of distorted judgements by NHS psychiatrists was uncovered by Home Office researchers two years ago who studied what actually happened when mentally-disordered offenders were transferred by courts to secure hospitals. They found that in reality, they were less likely than other patients to be violent on the ward or to re-offend after treatment: "The perception amongst some psychiatrists that admissions from court gain little benefit from admission, are more disruptive in hospital, fail to engage in follow-up, and rapidly offend upon discharge is almost entirely false."

NHS psychiatrists who turn their back on prisoners are aided by the fact that their hospitals have the right to refuse admission: prisons have no such power to refuse to hold an inmate, no matter how inappropriate. A senior forensic psychiatrist told us: "Putting mentally disordered offenders into prison is hugely ineffective. There is no argument against the moral point of view that they should be transferred. That is very strong. It is not just that the faciliities are not there. The whole ethos of psychiatry is against it."

Since Glenn Wright was returned to prison from Broadmoor, in March 2001, three more consultant psychiatrists have assessed him and deemed him suitable for transfer to hospital. Yet, he not only remains in prison but has, at times, been deliberately denied psychiatric care. He was held at Long Lartin for two months in early 2002, when the prison said explicitly that his regime would be one of containment and not treatment. Two years later, he was back in Long Lartin, where staff were instructed that he must be held in solitary confinement, exercised in isolation and denied access to a psychologist.

His self-harm now has become an explicit protest at the lack of treatment
for his mental disorder. Ironically, he has then lacked treatment for the physical damage he has caused himself. In March 2002, the general hospital at Milton Keynes, which serves Woodhill Prison, refused to remove jagged porcelain and batteries from his rectum, having already performed the operation twice before. In September 2002 and again in March 2004, the wound in his leg was untreated and said to be producing an unbearable smell. In some prisons, he is allowed to see a doctor only in the presence of six prison officers, leading him to refuse to have objects removed from his penis and backside. On other occasions, as part of his protest, he himself has formally refused to be treated.

The prison service reacted by continuing to shuttle him between prisons, despite the evidence that this was making his condition worse. In the second half of 2002, they moved him six times in seven months. Finally, in January 2003, he came to rest at Woodhill, where, for the first time in all his years in prison, he was given a full assessment and a care plan. He was given weekly meetings with a psychologist, and sessions in dealing with stress and self-harm. By April, he was showing signs of improvement and his meetings with the psychologist, which had originally been conducted through the hatch in his cell door, were held at a table.

Yet, despite this improvement, the prison service started to shuttle him again. In one prison, he claimed that officers in riot gear punched him and slammed his head against the floor. Another prisoner who was on a segregation unit with him, reported that officers were banging on Wright's cell door during the night to keep him awake and telling him: "As long as you are as you are, you're getting fuck all." The shuttling climaxed in a move to Long Lartin in March of this year, when the Woodhill psychiatrists complained bitterly that they had not been consulted and that the movement was causing his mental condition to deteriorate. Wright reacted in Long Lartin by putting shards of broken glass, porcelain and wood into his body, re-opening his leg wound and covering his body and his cell in his own dirt.

During this time, the Woodhill psychiatrists have tried repeatedly to transfer him to Rampton special hospital. In February 2002, Rampton agreed to assess him but kept him for only 36 hours before saying they could not help him. In November 2003, after his improvement at Woodhill, Rampton were sent three reports by senior forensic psychiatrists who agreed that he would respond to hospital treatment, but Rampton turned him down again without even seeing him.

Earlier this year, Woodhill applied to transfer him to Rampton's new unit for dangerous and severe personality disorders, one of four such units which are being set up by the government apparently to treat prisoners of exactly Wright's kind. This time, the Rampton admissions panel agreed that he had a personality disorder, noted that he had expressed motivation to be treated, acknowledged that he had been treated effectively at Woodhill but concluded that it would be "not appropriate" to give him a bed in the new unit.

Part of the difficulty here is that Wright is suffering from a personality disorder, ie behaviour distorted by earlier experience, and this is not regarded as an illness like schizophrenia. NHS psychiatrists often argue that personality disorder is not treatable and that it would be wrong to fill a scarce bed with somebody who cannot profit from it. However, we have spoken to senior forensic psychiatrists who say that this is too narrow an interpretation of treatment, that hospitals will take in a man who has been paralysed in a car crash, even though his condition cannot be cured, in order to help him manage his condition. The same logic, they say, should be applied to those who are mentally disabled and so a man like Glenn Wright should be given the systems and therapies that will help him to manage his condition, even if he cannot finally be freed from it.

Wright's disorder may be extreme, but the trap of 'untreatability' catches most of the estimated 50,200 men and women who have a personality disorder and who have ended up in prison cells. A survey of health trusts two years ago, revealed that only 17% of them were providing a dedicated service for personality-disordered patients, and there is only one secure residential unit in the whole of the NHS - Arnold Lodge in Leicester - which provides forensic beds reserved for them. Some units reject them as a matter of policy; others will admit them only in very small numbers; many also reject patients who have drug problems, which is commonly part of life for offenders with personality disorders.

Now, the government is proposing to change the law so that those who have disordered personalities can no longer be rejected as untreatable. Clearly, there is a benign argument for this, but there is also a real danger if the new law is not backed up by a regime of effective treatment. Without that, those who suffer from these disorders may be sectioned to secure hospitals and simply stored indefinitely even though they have not been convicted of any crime. The legal right to treatment makes sense only if there really is treatment on offer.

But the underlying problem for prisoners like Glenn Wright is that they are being managed by a system which insists on seeing them primarily as offenders who need punishment rather than as patients who need care. There was a poignant example of this in the case of a nineteen-year-old woman called Petra Blanksby. She was charged last year with arson with intent to endanger life and sent to Newhall Prison in Wakefield. But the life she had intended to endanger was her own: she had set fire to herself, and the flames had spread to her room. She had a long history of trying to hurt herself on more than 90 different occasions. Yet the system treated her as an offender and held her on remand in custody for 130 days. She hanged herself in her cell.

There are senior psychiatrists who are urging the government to mount a double-barrelled attack on the problem, by embarking on a major programme of investment in supported housing, employment and care in the community for mentally-disordered men and women; and by supplying the secure NHS facilities which would make sense of their claim to want to provide an appropriate bed for all mentally-disordered prisoners. These psychiatrists say the investment would yield a clear cost-benefit, particularly in crime-reduction.

In the meantime, tens of thousands of mentally-disordered men and women remain in prison, often deprived of the treatment they need. And several thousand of them, like Glenn Wright, are so severely disordered that they need hospital treatment. Once, in their struggle to contain him, officers locked Wright into a body belt in his cell. Within minutes, he had dislocated his own hip and wriggled free. The escape to hospital is much harder.

Additional research by Roxanne Escobales

See below for statistics and other case histories

NHS secure psychiatric beds -

* Institute of Criminology, Cambridge

Patrick Morley

Aged: 39.

Convicted: of rape, sentenced to life.

Diagnosis: psycopathic disorder.

In January 2000, after several years in prison, Morley was transferred to Rampton high-security hospital. There, he took part in a sex offenders programme, and, in January 2002, an independent psychiatrist reported that he was responding well and warned that he should not be returned to prison: "I have little doubt that if Patrick is returned to a purely custodial setting in which there was no understanding of his deficits and no capacity to work with him, the risk of repetition of his former anti-social behaviour on returning to the community, would be considerable."

Nevertheless, three months later, Morley was sent back to prison. A new doctor had taken over his case and told the Home Office that Morley had a bad attitude, was not responding to treatment and that he presented 'significant management problems'. Morley had been accused of sexually assaulting another patient, although no charge was brought. On the same day that they received this report, the Home Office agreed to move him.

In the background, two consultant psychologists and four trainees who had worked with Morley at Rampton objected to the move, warning that without this work, he was likely to commit more serious sexual offences. Another independent psychiatrist then reviewed the case and concluded: "I do not understand the rationale for prematurely curtailing Mr Morley's treatment at Rampton only for him to commence a similar programme in prison, but one in which the skills normally found in a hospital multidisciplinary team will be lacking." He added that evidence suggested that premature departure from sex offenders treatment programme actually increases risk of reoffending.

But the Home Office stuck to their decision. Morley's lawyers, Bindman and Co, went to court to complain, but the judges ruled that the decision of the doctor in charge was final, as long as it was fair and rational, and that the disagreement of others made no difference. Morley remains in a high-security prison unit.

Gary Frank*

Aged: 32.

Convicted: of rape, sentenced to seven years.

Diagnosis: severe mental impairment.

Gary Frank drove a car in which another man abducted and then raped a young woman. He was accused of knowingly assisting the attack. He was arrested and interviewed at length by police, prosecuted and tried, jailed and held in three different prisons without any of the police, probation officers, prison officers or prison nurses and doctors recognising that he was so mentally impaired that his IQ was in the lowest 0.1% of the population.

He could not remember his own birthdate nor count money nor tell the time. In prison, they recorded his condition: "Very distressed, not coping... Crying a lot... Not eating... Sitting on a chair in the dark... Says he wants to use a razor on his arms... Missing mum... A broken spirit, tearful." At Christmas, he asked if he could go home. The prison officers could see there was something wrong with him and took the highly unusual step of allowing him to sleep with his cell door open, and yet nobody diagnosed his severe mental impairment and nobody offered him any effective treatment for his depression, insomnia and anxiety.

His lawyers sent in a clinical psychologist who reported in some detail that he had "a very low level of intellectual functioning" and added that he was very distressed and not coping. The lawyers sent the report straight to the prison. Still he was offered no treatment, no move to the health care centre and no assessment to be transferred to an outside hospital.

Action was finally taken when a visiting consultant psychiatrist saw him, recognised his extraordinarily low IQ and severe depression and concluded that he was "one of the most ill-placed people I have seen in prison in 20 years of forensic psychiatric practice". Even then, the nearest secure hospital refused to take him, and the visiting psychiatrist had to spend nearly four months making phone calls and writing begging letters before somebody finally provided a bed in a secure unit. The court of appeal subsequently ruled that his statements to police and to his original trial were wholly unreliable, and overturned his conviction. Gary Frank said: "No wonder people commit suicide."

* Name changed at the request of the prisoner

Chris Edwards

Aged: 30

Arrested for: breach of the peace.

Diagnosis: mild psychosis

Chris Edwards was arrested for making inappropriate remarks to young women in the street. He had a history of psychiatric problems - some hallucinations, religious delusions - and he had been prescribed an anti-psychotic drug in the past. The police called a social worker to the cells where he was beating on the walls and removing his clothes and yet, despite all that, instead of using the 'place of safety' law to send him to hospital to be assessed, they charged him with breach of the peace and, for this minor offence, he was remanded to Chelmsford Prison.

That same evening, the prison was holding a man named Richard Linford, who was charged with serious assaults on a woman and her neighbour. He was being held in a single cell, because he had a history of far more severe psychosis than Chris Edwards as well as a record of violence which included an assault on a cellmate. On his previous sentence, he had been transferred to Rampton secure hospital. During the course of the evening, as more and more prisoners crowded into the jail, Linford was moved, to share a cell with Chris Edwards.

During the next three or four hours, prison officers realised that the alarm bell from the two men's cell was not working but did not investigate. At one point, they heard banging from a cell door on their landing. When an officer went to look, he found Chris Edwards had been beaten and kicked to death. One of his ears was missing. Linford had blood on his mouth and was talking about evil spirits. Chris Edwards had been in the prison for only nine hours.

An inquiry by police and prison services found that neither man should have been in prison and that Chris Edwards had been failed by "a systemic collapse of the protective mechanisms that ought to have operated". After the event, Linford was diagnosed as paranoid schizophrenic and belatedly transferred to Rampton high-security hospital.

Chris Edwards' parents subsequently sued and took their case all the way to the European Court of Human Rights. Two years ago, the court found that a series of errors had denied Chris Edwards his right to life. His parents continue to campaign for the government to make good its obligation to the court to erase such errors from the system.