A 59-year-old man with a history of psychiatric problems has been placed under investigation following the fatal stabbing of a nurse at the University Hospital of Reims in northern France on May 21st. The nurse, 39-year-old Carène Mezino, died from her wounds the following day. The suspect, named only as Franck F., is also being investigated for the attempted murder of a medical secretary, who was wounded during the same incident.
After his arrest the suspected killer's medical and legal records were quickly revealed. He has been receiving psychiatric treatment since 1985, having being diagnosed as schizophrenic and suffering from paranoia crises, and was under an enhanced form of supervision. In 2017 he had attacked four nursing staff with a knife at an employment centre for the disabled at which he worked. He was not placed in custody or put under direct judicial supervision after that attack, but instead placed in the care of a psychiatric hospital where he was detained until 2019. He subsequently spent two more spells in hospital, in 2020 and 2021. When not in hospital Franck F. still had to go to a psychological clinic each day to take his medicine there, and his treatment was supervised by a psychiatrist. He was also under the care of a court-appointed guardian.
The ongoing murder investigation has also revealed that these two experts had different views on the suspect's mental state before the attack. Reims state prosecutor Matthieu Bourrette said that Franck F.'s psychiatrist had considered his patient to be in a stable state, while the court-appointed guardian had “come to the view on several occasions that, since at least December 2020, he had no longer been taking his medication”. The initial findings of the investigation seem to suggest the guardian may have been right; some unused medication was found at his home.
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The patient's guardian also reported “several verbal crises since the summer of 2022, the last dated May 15th 2023”, according to the prosecutor. “She had informed the psychiatrist about this several times from 2021, reports which she says were not followed up,” said Matthieu Bourrette. The suspect's mother also feared that her son might again commit another act.
Pau, Thouars and Reims
The killing of Carène Mezino forms part of a tragic series of deadly acts committed by patients with severe mental illness. Two nurses died at Pau in south-west France in 2004 while a nurse was killed at Thouars in western France in 2020.
Politicians have cast around for the cause of such violence, such as a supposed slide towards “decivilisation”, to use the recent words of President Emmanuel Macron. Health minister François Braun has been more “pragmatic” in his approach, calling for an urgent assessment of the security systems in operation at health establishments while promising “zero tolerance” of violence and the adoption of practical measures. These include safer parking areas, the use of entry codes, security guards and so on.
However, as the minister himself agreed, it is difficult for hospitals to turn themselves into “fortresses”. The reason is simple: there are far too many doors in these very public places, where nurses, technical and administrative staff, patients, visitors and equipment suppliers of all kinds cross paths, and where vehicles of all types are coming and going.
Politicians meanwhile carefully avoid the key issue: that this violence is connected to public policies that have been implemented. In 40 years the number of psychiatric beds in the country has halved, partly as a result of the desirable aim of reducing reliance on “institutions” but also as a result of budget savings. At the same time, there has never been enough outpatient care available. Mental health clinics are collapsing under the pressure of demand and are having to make new patients wait months for an appointment.
“To respond to new requests we are forced to space out appointments in the mental health clinics,” says Delphine Glachant, a psychiatrist at the Les Murets psychiatric hospital near Paris and president of the professional body the Union Syndicale de la Psychiatrie. “When people have a breakdown we spot it less quickly and they break down more often. Our only response is isolation, which produces violence, more and more violence. That's my point of view.”
The 2011 security changes demanded by Nicolas Sarkozy
After the double murder in Pau Nicolas Sarkozy, who was minister of the interior and then president of the Republic, threw himself into the issue with some vehemence. During a speech in 2008, which left its mark on the world of psychiatry, he set out a security-based approach. This involved the creation of four special units for difficult patients, 200 isolation rooms, new measures to enable hospitalisation without consent, closed units, and files on patients hospitalised without their consent. The resulting law enacted on July 5th 2011 represented an unprecedented step backwards in the rights of such patients.
These political decisions were duly put into effect: between 2011 and 2021 the number of cases of care imposed without consent jumped by 14%, according to a recent study by IRDES, a public health research institute. In 2021 5% of people undergoing mental health treatment - in other words nearly 100,000 people - were forced to have treatment without consent. In the same year 10,000 people were restrained, that is to say attached to a bed in an isolation room. And these figures are incomplete and far from exhaustive, as the IRDES acknowledges.
Such measures, which are necessary when a person needs immediate care but cannot give consent because their mind is disturbed, should remain the exception. Yet France is one of the biggest users of such exceptional measures in Europe, and they are being used more and more often.
Two successive independent public officials - known as the Contrôleur Général des Lieux de Privation de Liberté (CGLPL), their role is to monitor institutions that hold people against their will - Adeline Hazan and Dominique Simonnot, have condemned the situation. In her 2021 annual report Dominique Simonnot criticised what she called these “most serious forms of deprivation of liberty, sometimes carried out amid great violence and conducted in disgraceful circumstances”.
In October 2022 the CGLPL published emergency recommendations following an inspection of a state mental health establishment at La-Roche-sur-Yon in western France. Her team saw locked doors in most of the units, even those for patients who were there voluntarily. Decisions to isolate and restrain patients, whatever the extent, were numerous and often illegal. Patients faced major obstacles in gaining access to their rights.
And yet these security measures have had no effect. Year after year, psychiatric care remains the medical service most afflicted by violence. Some 22% of reports made to the body that monitors violence in healthcare settings, the Observatoire National des Violences en milieu de Soins (ONVS), come from psychiatric services, far ahead of accident and emergency departments and geriatric units.
“Even in ideal [circumstances] there are dangerous patients in psychiatry,” acknowledges psychiatrist Mathieu Bellahsen, former department head at the Roger-Prévot hospital at Moisselles north of Paris, who was removed from his duties for having defended patients' rights (see Mediapart's investigation here). “But there are also patients who are made dangerous by an institution that ill-treats them,” says the doctor, who is preparing to publish a book against the use of restraint (read his blog on Mediapart here). “You have to avoid making people very hostile towards psychiatry. And take care of them at every stage, from the most open to the most closed stage,” he says.
For many in the sector the words of Carène Mezino's suspected killer – whatever credence one wants to give them – resonate strongly. According to prosecutor Matthieu Bourrette, the suspected killer said several times to the police officers who questioned him afterwards that he was “angry with the hospital world, saying he had been badly treated for several years by the psychiatric profession”.
The suspect's duty lawyer, Olivier Chalot, who has met him once, told Mediapart it had been a “difficult conversation with limited interaction”. The lawyer said his client was “simply angry. This anger focused at that moment on the 'white coats' [editor's, meaning medical staff]. I'm waiting to see what the psychiatric assessment says.”
I'm not attacking the patients but the system.
A psychiatrist at Reims and head of the Antonin-Artaud daycare centre there, Patrick Chemla is unable to comment on the care given to Franck F., as the patient did not visit his unit. But he says that “people who are very vulnerable mentally need a secure space, that should be the function of a public psychiatric service. At the Antonin-Artaud centre there is unconditional in-person and telephone access, 24/7. People can come for whatever reason, not just to see the psychiatrist, but to find a caring place”.
This method is what is known as institutional psychotherapy, born after the war as a reaction to patients being locked up. In the 1960s and 1970s it revolutionised psychiatry, with a reorganisation that brought it closer to where people lived.
“We've taken a huge step backwards,” says Patrick Chemla. “There are almost no more places such as ours. The state, with its policy of accounting evaluation, is against us. Academic psychiatry no longer believes in anything but medication, even though its effectiveness is limited. Psychiatric nurses no longer get any training. Yet the only therapy that has proved itself is human connection.”
Franck F.'s first victim, nurse Corinne Langlois, who was stabbed in 2017, spoke to France 3 regional television after the recent attack. She described the trauma she suffered six years ago, which still remains and prevents her from returning to work. She also said that when she first arrived at the employment centre where she was attacked she had “no knowledge of psychotic people”. Corinne Langlois said: “I didn't know what to do. I was just told never to get in front of them and to avoid dark corners. I don't understand: he had stopped his treatment a month before. No one had realised this. Why not? How is that possible?”
She insisted: “I'm not attacking the patients but the system.”
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- The original French version of this article can be found here.
English version by Michael Streeter