By Samantha Jones-
The psychiatric unit in Cygnet Hospital which failed the family of beautiful Sobhia Khan(pictured) should compensate the family be held to account for its shortcomings in supervising the killer.
They ought to compensate the family big for its woeful shortcomings and not wait for an official ruling to confirm the obvious- that they were simply too incompetent in doing their job.
Atual Mustapfa should have been monitored a lot better by the authorities, given his mental state, but he was negligently left to his own devices.
This 105-page study was commissioned by NHS England and carried out by Niche Health and Care Consultants.
It details a wide variety of chilling details about Mustafa’s past, his assessments by officials over the years and a large number of missed opportunities, missteps and miscommunication. This includes a repeated “over-reliance” from health officials on Mustafa to disclose concerns about his own behaviour and mental state – and risks he may pose to others.
It also includes evidence of repeated insufficient amount of consideration given to the risk Mustafa specifically posed to women, along with the impact stress has on his violent behaviour.
Psychologist notes in a report carried out during Mustafa’s time at Wathword Prison in Rotherham shortly before his transfer to Cygnet Hospital in Derby in early 2013 tell in chilling detail the risk Mustafa poses to those he is in an intimate relationship with.
The prison psychologist had written: “There is a risk of psychological and emotional abuse within the context of an intimate relationship.
“This may typically involve, although not restricted to; implicit threats of harm or violence, intimidation, insults, excessive monitoring of behaviour, isolating behaviour or withdrawal from supportive networks, financial abuse and using male privilege, all of which will render his partner’s life fearful and miserable.
“These behaviours are likely to increase when, for example, [Mustafa] feels insecure, criticised or jealous.
“Psychological and emotional abuse will likely start as soon as [Mustafa] perceives he ‘possesses’ his partner, like the very start of a marriage for example.”
This report was written four years before Mustafa murdered his wife, whom he had married in her absence just four weeks before.
The marriage process was called a nikah and involved Mustafa and his two friends as witnesses. It is not clear if Miss Khan was present, but the tradition states that this is not required.
Mustafa promptly collected Miss Khan from her family home in Bradford, and his brother and sister both saw Miss Khan on May 27, the day on which she was murdered.
His brother said he had seen Miss Khan wearing a headscarf very low, obscuring most of her face, and the sister saying she had been repeatedly asked to stay longer by Miss Khan.
The report also details that there was no evidence that the concerns of Mustafa’s first victim were taken into consideration in the decision to move him from Rotherham to Derby.
She had vehemently opposed the move because she still had family in the city, something Mustafa continued to lie about – saying she did not. This was never checked by the authorities, the report says.
The report also revealed the frequent lack of attention paid to potential stressors which could cause Mustafa to relapse – and potentially hurt women.
Stress in Mustafa’s personal and family life were seen as key triggers, noted in assessment reports throughout 2015, including in July 2015 when he was discharged from Cygnet to community care monitored by Derbyshire Healthcare NHS Foundation Trust.
Discharged
The crazy man was discharged from hospital to live on his own for the first time in seven years, to the house at which he committed the 2008 assault on his first wife, which was in need of a complete renovation due to disrepair. Months before, his dad died after prolonged illness.
A January 2015 risk assessment, carried out a few months before Mustafa was discharged back into the community, included the following types of violence it was “likely” he would commit: “Emotional abuse against ex-wife or intimate partner, physical violence against ex-wife or intimate partner, and sexual violence of a partner in the form of rape.”
It also said a “new relationship should trigger reassessment of risk”.
In monthly assessments, from April to July an assessment detailed: “If engaged in a close relationship and there was deterioration in his mental health state, there would be a high probability that he would engage in acts of violence against his partner within a couple of months.”
Brother Expresses Concerns At Inquest
On Wednesday, the brother of a West Yorkshire woman who was beaten to death by her husband said he has “a lot of concerns” about how authorities supervised the man responsible for her death, and that he wished he had intervened prior to her murder.
Sobhia Khan was killed by Mustafa at their house in Derby in May 2017, a month after she left her family home in Manningham, Bradford.
An inquest into her death heard on Wednesday how she was left with 36 individual injuries in the fatal attack, including being burned by an iron and struck by a bar or pole.
Her death came almost two years after Mustafa was discharged with conditions from a secure psychiatric unit in Derby, where he had been serving a hospital order for a sustained attack which saw him shave, beat, burn and set fire to another woman.
Javid Khan told Chesterfield Coroner’s Court that his family were “duped” by Mustafa, who was known to them by the false name of Asif from when he was first introduced in 2016.
Holding back tears, he said: “I have a lot of concerns and it has taken five years to get here.
“I want justice for my sister because if that happened to me, she would be sitting here saying the same thing.
“There are a lot of concerns and everything clicked into place after she died.
“I do beat myself up. I should have intervened as a brother.”
Evil killer:
The inquest is to examine the decision to discharge Mustafa from the Cygnet Hospital in Derby back into the community in July 2015, six years after he was diagnosed with paranoid schizophrenia following the first attack.
It will also examine whether the conditions attached to Mustafa’s discharge were fit for purpose and how his risk was assessed. The evidence strongly suggests his discharge was ill judged.
David Pojur, leading junior counsel to the inquest, told the court that conditions of his discharge included complying with appointments and medication, and notifying authorities if he started a new relationship.
Despite the “forceful and dominant” Mustafa posing “an obvious risk to women”, the conditions attached to his release into the community were not effectively monitored, Mr Pojur said.
He added: “Whilst there were many checks on his conditions, they mostly depended upon his self-reporting about how he was feeling, how he viewed his mental health, how he was taking his medication and whether or not he said he was in a relationship.
“Much was taken at face value.
“Even when questions were asked in the presence of family members, he lied about being in a relationship.”
The funeral took place in Manningham and attracted a large gathering (Image: T&A)
A friend, referred to only as Miss X, told the court she was told in early 2016 by Ms Khan that she had met Mustafa via Instagram but was keeping it from her family, and despite Miss X raising concerns about his criminal past, Ms Khan was “desperate to settle down”.
Miss X said she noticed bruises and burn marks after Ms Khan began visiting Mustafa’s Derby home, which the victim put down to being “clumsy”.
In his evidence, Mr Khan said that after Mustafa was eventually introduced, similar concerns were again dismissed, with Ms Khan saying Mustafa had been sentenced for drugs offences which he did not commit and that he was a “good lad”.
Mr Pojur said that the move to Derby was “the decline towards her death”, and in four weeks the “westernised” Ms Khan became “alone and increasingly vulnerable” and eventually “became a possession”.
She began wearing a full niqab and burqa, her social media accounts disappeared, her iPhone was replaced with a basic Nokia handset, and she was banned from making eye contact with men or touching them by accident.
Only after the murder did her family discover Mustafa’s real identity, and then found articles about his previous offending online.
Her brother told the court that had his family known about Mustafa’s past, his sister “would not have been going anywhere and would have still been here”.
he alleges that Mustafa told her he had bugged her house, had her watched, smashed her phone and she felt “threatened” by him.
It details, from a Cygnet internal review, that Mustafa’s “manipulative and intimidating and threatening behaviour in the relationship should have been seen as coercive and controlling”.
The report details that the fact that Mustafa had engaged in controlling behaviour, without the deterioration of his mental state, was “not given sufficient recognition”.
Three months later, in January 2015, the Ministry of Justice, unaware of the alleged behaviour of Mustafa during the relationship with a staff member, agreed to period of overnight leave from Cygnet to Mustafa’s parents house in Derby.
Shortly after his discharge and for much of the following four months, from August 2015 to January 2016, Mustafa was allowed to go to Pakistan to visit family. His father was extremely ill and was said to be unable to return. Mustafa’s father died on Christmas Day, December 25.
Mustafa had initially been given leave to go to Pakistan for a few weeks, before briefly returning. After that he was given leave to go to Pakistan for six weeks – with Mustafa instead choosing to book a four-month trip.
The Ministry of Justice also revealed that it had no legal ability to prevent Mustafa from going abroad.
The report says Mustafa had a “pattern of pushing boundaries” throughout his time at Cygnet and then in community healthcare – along with trying to ingratiate himself with staff throughout the period in custody and surveillance.
This pattern of pushing boundaries and the nature of the relationship with the staff member at Cygnet may have meant the Ministry of Justice would not have approved the initial Pakistan trip, the report suggests.
It says: “Clearly the MoJ can only act on information that is provided, and it is expected that clinical teams would provide timely accurate information.”
A damning indictment in the report’s conclusions is that officials placed too much of a burden on Mustafa to reveal his own issues, which may have in turn seen him brought back into hospital and many of his freedoms removed.
It says there was an “over-reliance on self disclosure with the expectation that [Mustafa] would volunteer any issues of concern”.
The report also says officials relied on Mustafa’s family to flag and identify concerns, instead of focusing on scrutinising Mustafa themselves, as qualified health professionals.
The report says: “In our view there was an unrealistic expectation that the family would tell the clinical team about his developing a relationship or not taking medication.
“His sisters and brother told us that they asked him about both of these issues, and were told aggressively that they should mind their own business, and he had told people what they needed to know.”
An internal report by Derbyshire Healthcare NHS Foundation Trust, detailed in the report by Niche, says that the impact of the transition from hospital to the community for Mustafa was “underestimated”.
It also says there was a lack of appreciation that the trip to Pakistan, shortly after discharge, should have been seen as a “significant event that would test his [Mustafa’s] coping mechanisms”.
An assessment of Mustafa in October 2015, on his brief return from Pakistan, the report says, inaccurately details that his previous violence towards women was directly influenced by his mental health.
The report says Mustafa’s risk to women was not directly related to his mental state, particularly due to the instances of sadism – pleasure derived from sexual violence – during the attack on his first wife in 2008.
Over the months in which Mustafa’s father was seriously ill and then died, there was a repeated lack of any investigation of Mustafa’s mental state, the report details.
The report details that health officials at Derbyshire Healthcare NHS Foundation Trust were completely unaware of whether there would be specific cultural dynamics to consider following the death of Mustafa’s father – when he became head of the family.
Mustafa’s family told the reviewer that after he became head of the family, Mustafa was “volatile and physically violent, unpredictable and aggressive”.
Cygnet also did not inform Mustafa’s GP about the crimes for which he was convicted in 2008, meaning they were completely unaware of his healthcare needs.
The report says Mustafa gave his GP a “highly sanitised” version of events in March 2015.
It also finds it “concerning” that Mustafa was described in an interview with them by senior Cygnet clinicians as a “perfect patient” who “had not put a foot wrong”, apart from the relationship with the member of staff.
Pushing Boundaries
The report details the “pattern of pushing boundaries” at Cygnet as sitting at complete odds with the assessment of Mustafa being a “perfect patient”.
This includes Mustafa manipulating a female member of staff who was managing an authorised escort, involving him getting into a car with his brother and asking for a lift back to the hospital along with the female member of staff.
It also includes being found with a smart phone in his ward, breaching the number of nights per week in which he could stay overnight outside of the hospital, lying about helping out his parents when they had already gone to Pakistan, and frequent breaches banning him from being left alone with children.
The latter breach included Mustafa being listed as the point of contact at the schools at which his nieces and nephews attended.
The report says there was a “degree of skill in successful subversion of boundaries at Cygnet and in the community under the care of Derbyshire Healthcare NHS Foundation Trust” and that this was “not always communicated or addressed effectively”.
Condolences
A spokesperson for Cygnet Hospital Derby said: “We offer our sincere condolences to all those affected and our thoughts are very much with them at this time.
“The patient in this case was discharged from Cygnet Hospital Derby in 2015, two years prior to the tragic events in 2017. We have accepted the recommendations of today’s report in full and are working to ensure all recommendations are fully implemented.”
Ifti Majid, chief executive of Derbyshire Healthcare NHS Foundation Trust, said: “On behalf of the trust, I welcome the publication of today’s report. We are fully committed to learning what we can from this tragedy in order to make improvements to our services and the way we liaise with other agencies about the management of patients who may present a risk to public safety.
“I would like to offer my apologies and condolences to the family of Sobhia for the opportunities that were missed through the care we provided. It is clear that Sobhia was a much loved, integral part of her family and that her tragic loss is still felt deeply today.
“In 2017 the trust undertook an internal investigation into the care and treatment provided to Mr A [Mustafa] prior to the events of May 2017. This investigation identified a number of ways the trust could improve the quality of our services and reduce the possibility of a similar event. An action plan was developed and we have made significant progress in implementing all of the recommendations. We will ensure these improvements are embedded and sustained into practice.
“Our services in 2017 were very different to those we have in place today. Four years ago we did not have a forensic community mental health team in Derbyshire, which was a significant gap in local service provision.
“In July 2019 a forensic community mental health team was commissioned for Derbyshire, to enhance our focus on public protection. The service aims to promote the mental, physical and social wellbeing of forensic patients and reduce the risk of re-offending to protect the public. This service continues to develop and is expanding to ensure the effective support and supervision of patients in the community.
“The responsibilities of this team include ensuring good and safe practice, including adherence to the Ministry of Justice reporting standards. We will ensure our practices are audited to confirm ongoing compliance.
“We are committed to working closely with and communicating effectively with our partner organisations. We have introduced a joint social supervision policy with both local authorities, which outlines the responsibilities of a social supervisor. We are also working together to employ forensic social workers in our forensic community mental health team and within the trust’s inpatient low secure services.
“We understand the importance of family engagement and of our services being culturally appropriate. We now have an enhanced auditing process in place to ensure that race, ethnicity, gender and religious issues are considered. We will routinely address these issues within our care plans.
Cygnet Hospital was asked by this publication whether they would compensate the family of the victim, and what actions were taken against the staff who had a relationship with Mustapha. They did not respond.
Secret Relationship
The inquest will also investigate Mustafa’s “secret sexual relationship” with a staff member at Cygnet Hospital.
It is claimed that the incident was inadequately assessed and that the “manipulative” Mustafa presented himself as a victim, despite evidence of controlling behaviour.
Mr Pojur said: “In echoes of his behaviour toward other women, he told her that he had bugged her car and knew where she was at all times.
“He also told her that he had bugged her house and had seen her having sexual intercourse with her husband.
“She admitted to providing a contraband mobile phone to him and having sex with him.
“She was swiftly dismissed.
“Mustafa, on the other hand, appears to have been treated as the wronged party, with no recognition that his behaviour towards the healthcare worker could be seen as offence-paralleling.”
The inquest continues.