COURT: This defendant was charged originally with one count of murder, but after psychiatric investigation it was established that she was suffering from a delusional disorder, a disease of the mind. A plea to manslaughter was accepted on the basis of diminished responsibility with the leave of the court.
The defendant admitted the facts and a conviction for manslaughter was entered. Thereafter, supplementary psychiatric reports were sought by the court with a request that the report focus on the appropriate treatment needed for the defendant.
The defendant who was born in mainland China married the deceased in 2004, after a courtship of six years. In 2009, she came to Hong Kong and lived with the deceased. The relationship was said by the defendant to have deteriorated after she came to Hong Kong. In 2011, the defendant moved out and lived alone, but in 2012 at the request of the deceased she returned to live with the deceased. The defendant worked throughout her time in Hong Kong.
The defendant who was aged 50 years at that time killed her 84-year-old husband on 29 November 2012. The cause of death was a stab wound to the chest and a cut wound to the nose. A secondary cause was Coronary thrombosis. The autopsy revealed that the deceased had severe Coronary artery disease, the left circumflex artery was occluded by an adherent thrombus, which would have accelerated death from the stab and cut wounds.
The rate of bleeding from the wounds was such that they were unlikely to have been instantaneously fatal, and the forensic pathologist opined that the deceased could have survived for some minutes and been capable of some degree of physical activity during that time.
The Forensic Pathologist also considered it possible that following the infliction of the wounds, death had been accelerated by a smothering of article such as a pillow.
In a cautioned interview, the defendant confirmed that she had attacked her husband while he was lying down asleep, and that he tried to resist. This was borne out by the autopsy results, as the deceased sustained what the ForensicPathologist surmised were defensive injuries. After stabbing and cutting him, the deceased said that she had used a pillow to suffocate him.
The weapon used was suggested by the Forensic Pathologist to be probably a single-edged knife with a blade of not more than 3 centimetres, and a length of not less of about 11 centimetres. Later, the pathologist examined a knife identified by the defendant as one she had taken from the kitchen.
That knife was sharp, single-edged with a pointed tip, the tapering 20 centimetres long. It was 3.8 centimetres wide at the hilt, and 3.1 centimetres wide at a distance of 11 centimetres from the tip. The pathologist confirmed that the measurements of the knife were consistent with the dimensions of the stab and cut wounds on the body, and the deceased’s injuries could have been inflicted by that knife.
The defendant gave a video-recorded interview and took part in a crime reconstruction. She described the killing as resulting from her anger at the deceased’s course of conduct, which she guessed included spying on her in the bathroom and distributing the result in photographs to her colleagues, turning on the radio loudly to prevent her from sleeping, and immediately prior to the killing of stealing HK$1,000 from her, which led to a quarrel between them.
The defendant’s evidence is that at about 2 am on 29 November 2012, she felt that the deceased was like a devil, and that the devil had to be killed. She took a knife from the kitchen and stabbed the deceased who was sleeping. The deceased woke and struggled with her. She kept on stabbing him and later held her over his face until he stopped breathing.
She took a knapsack, put a telephone and an umbrella in it, locked the house and then climbed up the hillside behind the Tsz Ching Estate. She said she felt numb, very confused, was in a bad mood, felt she was in a trance and wanted to commit suicide.
Eventually, she telephoned the police telling them that she had killed the deceased. The police had to rescue the defendant from the hillside as she was unable to get down without assistance.
There was no dispute about the facts of the killing. The defendant knew what she was doing and intended to kill the deceased.
The defendant was not known to the Psychiatric Services in Hong Kong prior to the killing. An examination did not reveal any family history of a psychiatric condition.
After her arrest, the defendant was remanded in Tai Lam. On 6 February 2013, she was sent to Siu Lam Psychiatric Centre for assessment by the visiting psychiatrist, Dr Amy Liu Ching-yung. At that time, the defendant was the only source of information about events before the leading up to the killing. Dr Liu was unable to diagnose any formal psychiatric illness, although she assessed the defendant, at that stage, as having significant personal difficulties.
The defendant was examined after that by Dr Peter Yu Wai-tak on the instructions of the defendant’s legal representatives.
In his report dated 13 February 2014 after accessing a lot of peripheral material, Dr Yu opined the defendant was suffering from delusional disorder. The material on which that diagnosis was based included the trial bundle, the video interview, the medical report of Dr Pang Wai-keung, the report of Dr Yu dated 29 January 2014, and a police incident report of 28 February 2012.
Subsequently, Dr Liu examined the defendant on 7 March 2014. At that time, the same type of information was available to her, as was Dr Yu’s report of 13 February 2014. In her second report, dated 7 March 2014, Dr Liu was able to agree with Dr Yu’s assessment of the defendant’s condition. The witness statements of the defendant’s colleagues were largely instrumental in establishing the defendant’s complaints as resulting from her paranoia rather than having any basis in reality.
Subsequently, each of Dr Liu and Dr Yu, at the request of the court, prepared supplemental reports relating to the prognosis and treatment of the defendant, as well as the best place for her treatment.
The question of prognosis and further treatment was canvassed by both psychiatrists. Each agreed that the defendant suffered delusional disorder and that she had been suffering from those delusions at the time of the killing.
In essence, each agreed that what was required for the defendant was long-term treatment which had to be supervised because the appropriate treatment involved the long-term administration of antipsychotic drugs, psychosocial treatment and the treatment needed to be administered through in-patient care.
Ultimately, each agreed that the proper course to be followed was for the defendant to be made subject to a Hospital Order under section 45 of the Mental Health Ordinance, with such order to be of unspecified length. Under such an order the defendant would be subject to the overview of the Mental Health Board of Review, with the defendant being able to seek a review after the first 12 months of her being made subject to the order.
The only serious difference between the two psychiatrists was whether the order would be better served at Castle Peak Hospital or in the Siu Lam Psychiatric Centre.
In this regard, both Dr Liu and Dr Yu gave thought to whether the defendant was liable to prove a danger to herself or other persons in the future, and there was some divergence of opinion on that matter.
Dr Yu made his prognosis in his report of 13 February 2014. He said that the defendant had a good chance of recovering from the illness after appropriate treatment. She does not have a violence propensity. An isolated violent act is not indicative of a violent propensity. The crime was committed only when she was deluded or suffering the illness at its worst. She is very unlikely to suffer the same worsening as long as she is receiving treatment. Despite harbouring persecutory delusions against her husband defendant had been a devoted wife.
As can be seen, Dr Yu did not consider the defendant posed any future risk to others, and he submitted that Castle Peak Hospital was a better place for the defendant, that if she was in Siu Lam with its more regimented supervision, she was likely to become institutionalised.
He considered that the defendant’s delusional disorder was linked to and had been triggered by her then poor relationship with her husband. As her husband was dead, the likelihood of the defendant re-offending was negligible.
Dr Yu focused in his report on the defendant’s delusions about her husband, but he did not really address the fact that the deceased was not the only focus of the defendant’s delusions behaviour, so too were her colleagues at work, as well as her neighbours.
Further, Dr Yu did not address the possible problems which could arise because of the defendant’s refusal to take medication. The defendant had all along refused psychiatric treatment, and was still delusional at the time of sentencing.
Rather unsurprisingly, for that reason Dr Liu had a less sanguine view of the defendant’s likely of re-offending. This was based on the defendant’s consistent and continuing refusal to take any of the recommended drugs designed to deal with her illness over a necessarily long period.
Defence counsel, during his mitigation, advised the court that the defendant was refusing medication because of her belief that there could be possible deleterious effects to herself from that treatment, although those defects were not particularised.
Dr Liu, in her role as visiting psychiatrist had had the opportunity of examining the defendant repeatedly at Siu Lam Psychiatric Centre, the defendant having been sent there first on 6 February 2013 for investigation of alleged persecutory delusions. Again, on 30 October 2013 she was transferred to Siu Lam again because of persecutory delusions and interpersonal difficulties.
During that period the defendant complained to Dr Liu that CSD staff at Tai Lam treated her unfairly, but despite that when she was seen by Dr Liu on 10 December 2013, she was unhappy that Dr would not transfer her back to Tai Lam. Dr Liu commented on the defendant tendency to blame others for treating her unfairly whenever her demands were not met.
In her third report dated 24 March 2014, Dr Liu at paragraph 4 stated that during her 12 months in custody the defendant had demonstrated her strong resistive attitude to being diagnosed as suffering from mental illness, she strongly refused psychiatric treatment all along, her insight towards her mental illness is regarded as very poor. On the other hand, her persecutory delusions, especially those against the deceased, are persistent until now.
At paragraph 5, Dr Liu concluded that in view of her persistent delusional beliefs, her poor insight and compliance to treatment, further inpatient psychiatric treatment was definitely warranted in the case of the defendant.
At paragraph 6 of that report, Dr Liu wrote:
“Fang is recommended to serve the Hospital Order at Siu Lam Psychiatric Centre instead of Castle Peak Hospital. Siu Lam Psychiatric Centre is a maximum security institution run by the Correctional Services Department, while Castle Peak Hospital is a mental hospital being run by the Hospital Authority. All nursing staff at Siu Lam receives standard training by CSD, while nursing staff at Castle Peak just received ordinary psychiatric nursing training.
In short, the level of security at Siu Lam in terms of its facility and services is much higher than Castle Peak.
Madam Fang undoubtedly manifested serious violence at the time of the indexed offence. Her violent propensity is regarded to be high for two reasons:
First, a history of violence under psychotic influence is a strong indicator on future violenct risk
Second, even more importantly, Fang still manifests the persecutory delusions, and she is also observed to be prone to form paranoid beliefs against others. This could further heighten her risk of violence.”
Dr Liu continued,
“Given the high propensity of violence, Castle Peak Hospital is definitely not a suitable place for Fang to serve the Hospital Order at the current juncture”.
And I would emphasise here the words “at the current juncture”.
“Moreover, as illustrated above, Madam Fang has clearly demonstrated her lack of insight and non‑compliance to treatment. Her resistive attitude towards psychiatric diagnosis and treatment can lead to risks of abscondence. This further explains the unsuitability for her to serve a Hospital Order at Castle Peak Hospital at the present juncture.”
In looking at the opposing views, I concluded that either Castle Peak Hospital or Siu Lam Psychiatric Centre would be able to adequately administer a Hospital Order, but as a matter of common sense, whether a patient was sent to one or the other facility must depend on the condition of the patient at the time the matter fell to be decided.
Given the defendant’s refusal to take medication, and her intransigent attitude to what both doctors agree was a vital limb of her treatment, it would be extremely difficult to justify placing defendant in her unmedicated psychotic condition at Castle Peak Hospital, at least initially.
The matters which Dr Yu points out as being desirable and advantageous to the defendant in terms of her long-term supervision, are also those factors which provide the possibility of danger to staff and patients with whom the defendant has contact. In her untreated state, the defendant has a higher propensity to violence if thwarted in some way.
It may be the case that the defendant never resorts to violence again, but given her attitude and noting that her delusions persist still, it is a risk the court cannot permit by its order.
Dr Liu has stated that the appropriate treatment calls for the defendant to go first to Siu Lam Psychiatric Centre, and when her condition has stabilised and, if appropriate, she can be transferred to Castle Peak Hospital for the latter part of the treatment.
For such progression to occur, the defendant needs to comply with the drug regimen proposed for her. It may be that if the defendant realises that compliance is a major factor in her being considered for eventual transfer to Castle Peak Hospital, she will have gained sufficient insight into her illness as to her make her amenable to accepting the suggested treatment.
Accordingly, I make a Hospital Order, and order that Madam Fang be admitted to Siu Lam Psychiatric Centre, pursuant to the provisions of section 45 of the Mental Health Ordinance, such order to be for an unspecified period.