SP(Risk-Suicide-PTSD-IFA-Medical Facilities) Kosovo CG  UKIAT 00017
Date of hearing: 4 February 2003
Date Determination notified: 01/07/2003
|Secretary of State for the Home Department||RESPONDENT|
For the Appellant: Mr. F. Gaskin, of Counsel, instructed by Reid Sinclair & Co. Solicitors.
For the Respondent: Ms. C. Hanrahan, Home Office Presenting Officer.
"Another noteworthy finding in the present study was that suicidal behaviour did not differ significantly between asylum applicants and refugees granted residence permits. Thus the notion that asylum applicants might manifest a higher frequency of suicidal behaviour, possibly due to the threat of imminent expulsion from the country, derived no support from our findings".
Evaluation of the medical evidence
The approach of the appellate authorities
a) It is not the job of an adjudicator to make clinical judgments. That is the job of medical experts. Equally, however, it is not the function of medical experts to evaluate conditions in an appellant`s country of origin. Except in very rare cases they have no expertise about such matters.
b) Albeit not medical experts, adjudicators are perfectly entitled, when evaluating a medical report, to consider to what extent it is based on established medical methodology and criteria. Adjudicators should obviously be cautious about criticising medical reports unnecessarily, particularly given that they do not have the benefit of a medical report from the respondent so as to enable a comparison to be made. But by virtue of the frequency with which the immigration appellate authorities have to examine and assess medical reports in asylum-related cases, a fund of experience and knowledge has been built up, making it possible to identify what is expected from a "good report", and to discern which medical experts, among the many whose reports they see, produce reports based squarely on established medical methodologies and criteria. If confronted, therefore, with a diagnosis (or prognosis), which departs for no good reason from methodology and criteria established within the medical profession, they cannot be expected to overlook that kind of deficiency. And to the extent that a medical report fails to base itself on established medical methodologies and criteria, an adjudicator may be justified in attaching lesser weight to it as a consequence. A medical report purporting to give an in-depth diagnosis of PTSD based on one superficial interview is an obvious example. As the Tribunal highlighted in AE and FE, an adjudicator is also entitled to assess to what extent a medical report is based on examination which has been conducted as soon as possible after the time of the injury or event which is said to have caused the physical or psychological disorder.
c) Irrespective of the quality of the medical report, the assessment of risk upon return that has to be made by an adjudicator must be based on the notion of real risk as established by refugee law and human rights law. That will not necessarily be the same concept of real risk applied by medical experts.
d) Since an adjudicator must base his assessment on a consideration of all the evidence viewed in the round, it is always ultimately a matter for an adjudicator what weight if any to attach to medical evidence. In order to assess whether there is a real risk, the medical evidence has to be placed alongside all the other evidence. Where a doctor's report has based some of its key findings on the truth of what his patient has told him about past experiences and/or current fears, it may well be that an adjudicator who having made a global assessment finds the appellant`s account not credible, will reject that report`s principal findings. Depending on the particular circumstances, medical evidence stating that a person`s injuries or condition is "consistent with" his account of what happened to him in his country of origin may or may not add credence to his claim.
The treatment of self-harm by Strasbourg jurisprudence
The current medical approach to suicide cases
"Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide".
"Frequently there may be thoughts of death, suicidal ideation, or suicide attempts (Criterion A9). These thoughts range from a belief that others would be better off if the person were dead, to transient but recurrent thoughts of committing suicide, to actual specific plans of how to commit suicide. The frequency, intensity, and lethality of these thoughts can be quite variable. Less severely suicidal individuals may report transient (1-2 minute), recurrent (once or twice a week) thoughts. More severely suicidal individuals may have acquired materials (e.g. a rope or a gun) to be used in the suicide attempt and may have established a location and time when they will be isolated from others so that they can accomplish the suicide. Although these behaviours are associated statistically with suicide attempts and may be helpful in identifying a high-risk group, many studies have shown that it is not possible to predict accurately whether or when a particular individual with depression will attempt suicide. Motivation for suicide may include a desire to give up in the face of perceived insurmountable obstacles or an intense wish to end an excruciatingly painful emotional state that is perceived by the person to be without end.
A diagnosis of a Major depressive Episode is not made if the symptoms meet criteria for a Mixed Episode (Criterion B). A Mixed Episode is characterised by the symptoms of both a Manic Episode and a Major Depressive Episode occurring nearly every day for at least a 1-week period. The degree of impairment associated with a Major Depressive Episode varies, but even in mild cases, there must be either clinically significant distress or some interference in social, occupational or other important areas of functioning (Criterion C). If impairment is severe, the person may lose the ability to function socially or occupationally. In extreme cases the person may be unable to perform minimal self-care (e.g. feeding or clothing self) or to maintain minimal personal hygiene".
"Individuals with a Major Depressive Episode frequently present with tearfulness, irritability, brooding, obsessive rumination, anxiety, phobias, excessive worry over physical health, and complaints of pain (e.g. headaches or joint, abdominal, or other pains). During a Major Depressive Episode, some individuals have Panic Attacks that occur in a pattern that meets criteria for Panic Disorder. In children, separation anxiety may occur. Some individuals note difficulty in intimate relationships, less satisfying social interactions, or difficulties in sexual functioning (e.g. anorgasmia in women or erectile dysfunction in men). There may be marital problems (e.g. divorce), occupational problems (e.g. loss of job), academic problems (e.g. truancy, school failure). Alcohol or Other Substance Abuse, or increased utilisation of medical services. The most serious consequence of a Major Depressive Episode is attempted or completed suicide. Suicide risk is especially high for individuals with psychotic features, a history of previous suicide attempts, a family history of completed suicides, or concurrent substance use. There may also be an increased rate of premature death from general medical conditions. Major Depressive Episodes often follow psychosocial stressor e.g. the death of a loved one, marital separation, divorce). Childbirth may precipitate a Major Depressive Episode, in which case the specifier with Postpartum Onset in noted."
The medical evidence in this case
- Report of 11 October 2001 from Mr Andrew Robinson, Care Manager, West Berkshire Social Services Adolescent Team. Mr Robinson notes that aside from the psychological issues relating to PTSD Mr Plaku had not presented any health issues and has made good progress in studies and in vocational work and had friends in Oxford and in Reading. He had adequate self care skills and was said to be "… a mature young man who has survived great adversity".
- Psychiatric Report by Annette Goulden, Consultant Child and Adolescent Psychiatrist dated 7 January 2002. In her "Summary" she stated that the appellant demonstrated all the diagnostic criteria for PTSD. His sleep was helped by medication but he had told her it made it difficult for him to wake up in the mornings in order to attend college so he stopped taking the tablets. He had an unresolved bereavement due to the death of his other family members, particularly his parents. This compounded the emotional trauma consequent upon the PTSD. She concluded as follows:
"If Mr Plaku returns to the situation where these traumatic events took place, he will without doubt re-experience the trauma emotionally, physically and psychologically. Undoubtedly, Mr Plaku has been supported since his arrival in the UK and has made excellent use of any opportunity offered to him, e.g. to learn English and start training as a chef. However, independently of any other motives he may have to remain in this country, I am confident that he has Post Traumatic Stress Syndrome and unresolved bereavement, with guilt about survival and self-blame.
My belief is that if Mr Plaku returns to his own country there is a high risk that he will take his own life in order to avoid re-experiencing the traumatic events of his childhood".
- Addendum Psychiatric Report by Annette Goulden on appellant dated 31 January 2002. In this report Dr Goulden set out her diagnostic criteria for PTSD and went on to summarise what the appellant had told her in the course of two interviews in November and December of 2001. We have already noted the sources and studies she said she relied on. At paragraph 16 with reference to the November interview she wrote:
"His mood was consistently serious and low and his facial expression masked. He told me he had suicidal thoughts but had no real intention of taking his own life at this time. "
"Mr Plaku`s description of events and of his current mental state accords with the DSM IV criteria for PTSD. Both Criteria for Section A are fulfilled. At least three of the criteria from Section B are met. Most of the criteria from Section C are described and at least three of those in Section D. E and F criteria are also present. Duration is chronic (more than three months) and not likely to be of delayed onset".
- Addendum Psychiatric Report by Annette Goulden on appellant of 25 March 2002. In 5c of this report, Dr Goulden said that in the course of his two interviews which took place before her original report, the appellant had described two clear and serious suicidal attempts while in Kosovo. In 5d she said the appellant had described persistent low mood with bleak and pessimistic views of the future and persistent suicidal thoughts when he is alone. She said he had told her he would kill himself if he returned to Kosovo "and, in view of the general truthfulness of his account, I have no reason to disbelieve this".
"It is well-recognised that re-exposure to the scene of the traumatic event causes the person to be re-traumatised. It is for this reason that people with PTSD make huge efforts to avoid revisiting the scene of the trauma, whether it is in the physical state or the memory state…. Facing the traumatic past without the support of a stable home environment, social network and therapeutic setting may be intolerable and precipitate severe avoidance reactions such as suicide….".
"I believe Mr Plaku is at serious risk of committing suicide if he returns to Kosovo. This is based on my assessment of his current mental state of chronic depression, together with a diagnosis of PTSD within the context of lack of family support in Kosovo and the low likelihood of the intensity of treatment he requires. …Thus, a return to his country will re-expose him not only to the memories of being burnt, but also to longer term traumatic events of his adolescence. Re-stimulation of these memories, together with the impact of bereavement from his family, could lead to unbearable recurrence of trauma. This would be within the context of the further loss of his educational and social attainments in this (sic) UK so far and major adjustment required for any person returning to Kosovo.
- Letter of 22 October 2002 from Dr Michael Hobbs, Consultant Psychotherapist, Psychotherapy Department, Oxfordshire Mental Healthcare NHS Trust. He said he had not seen reports from Dr Goulden "but Mr Plaku`s suicide risk was identified by Suzanne Rose (Clinical Nurse Specialist in Psychological Trauma with the Berkshire Psychological Injuries Unit) who referred Mr Plaku to me earlier this year. When I interviewed Mr Plaku first on 14 March 2002, he acknowledged that he had considered suicide at times since escaping from Kosovo in autumn of 2000.
- Report by Liben Gebremikael, Coordinator Refugee Resource, Woodpath Project dated 24 January 2003. In describing his background she noted that:
"He also had active suicidal thoughts and had once attempted to commit suicide in the autumn of 2001. He has clearly expressed to me that if he was made to return he would rather kill himself here than face the harassment, torture and death at the hands of the gang members from whom he managed to escape in the past…. Mr Plaku has once attempted suicide here and this makes me take the threat of attempting against very seriously".
The issue of real risk to this appellant
"Although mental health provision in Kosovo is relatively undeveloped, treatment for psychological conditions including Post Traumatic Stress Disorder in available in Kosovo. Details of the "Kosovo Rehabilitation Centre for Torture Victims (KRCT)" which provides treatment for PTSD are included in the source materials"."
"Differentiation between mild, moderate, and severe depressive episodes rests upon a complicated clinical judgement that involves the number, type, and severity of symptoms present. The extent of ordinary social and work activities is often a useful guide to the likely degree of severity of the episode, but individual, social and cultural influences that disrupt a smooth relationship between severity of symptoms and social performance are sufficiently common and powerful to make it unwise to include social performance amongst the essential criteria of severity".
DR H H STOREY