Recently compiled report by the charity Inquest.
Deaths in mental health detention: An investigation framework fit for purpose? (10 February 2015)
http://www.inquest.org.uk/publications/books/deaths-in-mental-health-detention-an-investigation-framework
Free PDF. Printed copies can be ordered.
Tuesday 24 February 2015
Monday 23 February 2015
Norfolk and Suffolk mental health trust in special measures (BBC 19 Feb 2015)
Norfolk and Suffolk health trust in special measures BBC 19 Feb 2015
http://m.bbc.co.uk/news/uk-england-norfolk-31532241Own thoughts: It’s good to see that the CQC have teeth when it comes to assessing mental health services. Everything I had read up to now had suggested that they were not as equipped to deal with non-mainstream services, where the focus is on matters of hygiene and malpractice in operations etc.
Mental health deaths in detention "avoidable" (BBC Article 23 Feb 2015)
BBC News 23 Feb 2015
Mental health deaths in detention 'avoidable'
Findings from an enquiry by the Equality and Human Rights Commission.
Friday 13 February 2015
Email to LPT re. Safeguarding J and unworkable care plan
For Customer Services - feel free to forward this email to others.
Patient: J-
Inpatient on H-- Ward (Bradgate Unit)
Myself,
Carer/partner/next of kin: (name and address etc)
13th February 2015
Dear Sir / Madam,
I am frightened that my partner (J) is in a very real danger, of the kind that I hoped a hospital admission would prevent. Last week she was allowed to leave the ward by Dr D-, after she had repeatedly told staff (over several hours) that she planned to kill herself on the A50.
(I'm attaching map of her route from the entrance to the road taken on Wednesday 4th February 2014).
(Edit: blog readers: for map see earlier post)
The nurses had encouraged her to stay on the ward until Dr T and Dr D were available to talk to her. I was visiting that day. When I arrived she was pleading with nurses near the ward entrance to let her go so she could kill herself. Both doctors, attending later, reiterated that if J was to leave the ward that she would be "refusing treatment" and would be discharged, and, importantly, would not be stopped by staff in the hospital. They said she was "free to leave" the ward, adding "perhaps for a walk". J again said that she planned to kill herself on the road.
When J left the ward via the MDT Room door to the corridor, wearing only slippers and a seclusion gown, on February 4th, at no point did Dr D raise the hospital alarm. The only extra help we had by the road, pushing J back from the road was from two female nurses who were on a break from other wards. It was purely upon our own instincts did, the ward matron and I follow J and Dr D - who was still asserting that J and her were "going for a walk". I don't understand why there wasn't a lock-down of the intercom doors, J managed to leave the building faster than I have been able to enter when visiting (J is also unable to run due to swelling in her legs and back pains). Dr D was happy to have the police called (but no point did she use a holding section). The police finally arrived, after a our long struggle by the road-side, and J, exhausted, was driven back to reception.
The whole event was distressing for all. This letter/email is not a formal complaint about that avoidable incident, but I am using the incident as an example of why I am concerned about the care plan conditions of J's stay on H-- Ward.
H-- Ward is a preferential choice for J, she gets on well with the nurses and having her own room is invaluable and essential for her recovery. We are very grateful for this. J also trusts Dr D to help with a gradual change in medication. I don't believe she would want to change the ward or consultant. I have mixed feelings about this.
My main issue is with the arrangement/ behaviour contract of her stay, written into her care plan, which I think is supposed to help J, in a voluntary way, to "own" her recovery, but in fact is negative, blame-based, emotionally invalidating, lacking in compassion or empathy, devastating to her self esteem and alienating for both her as a patient and myself as her carer.
J has been told by the Dr D (and it is written in the care plan) that any acts of self-harm or suicide will be interpreted as "a threat" and she will be immediately discharged from ward care. Dr D has said that J will also discharged from all community treatment (terminating continuity with a CPN, a new psychiatrist and an OT). Can she really do this?
J believes that by even expressing a desire to self harm will lead to this punitive action.
I do not believe that J is given any genuine choices here. This must be disempowering and can add to the sense of feeling trapped and low self worth (on top of wanting to kill herself).
It was always my understanding in the past that if a ward cannot treat or help J to recover that she would at least be kept safe until an alternative therapy is found. There is so much misery in J's day to day life, that an invitation to leave the ward whilst she is at her most in pain, merely confirms for her that staff want her "to be dead".
In the debriefing meeting after the road event, J was told by Dr D, that by her wearing a seclusion gown, whilst leaving, it would be classed as "theft of hospital property" (this was also inferred beforehand, because at that point, she offered to pay for the gown). To me, this sounds like the gown was of more value than the life of my partner. Charging a dead person with theft makes no sense. It is not a sensible deterrent.
I wasn't at the debriefing, but J has informed me of other things that Dr D said to her:
"She also told me she is going to be having a meeting with the police to tell them that if they are ever called out to help in a crisis situation, they are not to intervene or get involved in anyway, and should let me kill myself. She is already thinking about what to say to the coroner at the inquest into my death, feeling satisfied that she is blameless/faultless, and she is merely waiting for the inevitable."
Regarding the coroner remark, even if this is psychological coercion to stop Jo trying to kill herself, it is in extremely poor taste. We are reminded of the inquests that have been reported in the local press regarding deaths of inpatients at the Bradgate Unit.
Dr D has also told me on two occasions, in person, that "you cannot prevent people from killing themselves". I've pointed out that the new doors at the Bradgate had been doing just that, she didn't seem to feel that that was relevant. Even when a patient is voluntary, the doors can remain closed whilst a patient is talked down, even before anything legal has to occur.
Regarding police not helping J - I don't understand how this can work. In the same way that Dr D felt that she could stop traffic, when (ironically) putting herself and motorists in danger, whilst we kept J on the verge, she believes she can order the whole of the Leicestershire Constabulary to allow J to leap from a motorway bridge. I can't imagine what J makes of this. Suicidal J might be even be relieved to hear this, since it was the police who brought her to hospital, in a prisoner cage in a van (after I had called them).
I believe it is very unfair on the nurses to allow her to leave the ward if they think she's not thinking clearly, as was the case on Wednesday 4th. Some of the nurses on H- Ward who had been trying to keep her safe have even told J that "... they believe that I did NOT have mental capacity at that time. They also believe her [Dr D's] current and ongoing attitude towards me is punitive, and far from supportive or therapeutic." (J's own words)
When J is frantic and suicidal, she says that killing herself is the "best thing" and that all alternative paths are "illogical". By my definition she is unable to make a decisions or choices (other than those which end with self-destruction) and could be considered to be mentally incapacitated. I have seen her beg policemen to take her to the motorway, as if they were a taxi. I have seen her beg nurses to let her die. These are not rational choices.
Incidentally her medication dosages had already been reduced on the day the road incident occurred, and yet this was not seen as an endangering factor.
J is co-operating with her care to the best of her ability, she is taking a keen interest in the change of her medication, she sometimes makes friends with staff and other patients, when her anxiety allows.
I cannot keep her safe at home when she is unwell, I cannot legally lock the doors or take away her medication to prevent an overdose. She doesn't "want" to be in hospital, who would "want" to be at the Bradgate Unit (?) but she in-part acknowledges the need to be kept safe, whilst also wanting to be dead. I don't think she has the inner strength (because of low mood and low self-esteem) to just "turn off" suicidal urges in response to a care plan contract, otherwise she wouldn't need to be in hospital. Also, her medical history (including ward stays) is repeatedly used against her by assessors and the consultants, as if imply that she is somehow "dependant" on services. Again, this creates negative reinforcement that she cannot be helped by the NHS and is alienating for us both.
I am unsure how to proceed. I thought about meeting with the ward matron (-), but since she was present for the whole of the road incident I'm pretty sure she knows my opinions on these matters. Without the blessing of the consultant, would the ward matron be able to change anything? I.e. overturn Dr D's directions re. J's safety and day-to-day care? J wants to remain on the ward under the care of Dr D, but neither of us feel the threat of treatment-denial is useful to her recovery. It is not a true partnership between patient and doctor, despite Dr D's repeated use of the phrase "are we agreed?"-usually after presenting an ultimatum (certainly forgetting that the patient is relatively powerless at the best of times).
Would it help if the unit managers were made aware of tactics like these, where a patient's life is gambled with? (I'm not being rhetorical, there may be a broader picture here.) Do they have a say in these matters?
This is difficult for me because the LPT is involved with every aspect of J's mental health care, from community team, ward staff and home treatment (crisis teams). We have come a long way, and there's been plenty of positive advice and coping strategies, plateaus of stability, amidst occasionally bumpy care in hospital and relapses at home.
Somehow in all of this J believes she is "wasting everyone's time" and is "better off dead". The scenarios and methods of death never leave her, but her resistance weakens. She is not impulsive, it's just that during the tougher moments these planned suicide scenarios seem normal for her to take to their conclusion (which may also relate to her OCD mindset, where completion is paramount). Her suicidal behaviour has nothing to do with wanting care. Therefore her self-harm and suicide attempts are not a manipulative currency of blackmail. I want to put this absurd idea to rest. Frankly some of the ward care just isn't that great when compared to being at home, but sometimes it's a grim necessity. She would not have adopted a cat if she thought she was going to be spending time in hospital.
Every day this arrangement with Dr D continues I believe that J is very unsafe. I would like to see a rapid resolution, or some sort of mediation between us and Dr D. I regret to say that in the past I have become frustrated by the Trust, in some cases taking up to three months to respond to what were very immediate ward care issues. Even advocacy groups can take up to two weeks to write letter representing a patient or carer's views to staff. This is why in the past, being so frustrated, I've turned to organisations like the CQC, posted online and even written to newspapers (such is my desperation). There is also no point of me going to the Ombudsman until a complaint has been resolved (I think). I am grateful for replies when they do arrive, but unfortunately circumstances have often changed and the damage has already been done to Jo.
I am open to any suggestions to resolve any of the above issues and am also in favour of face to face meetings, or just phone me or email me.
Since J is currently residing on H-- Ward, I recommend sending permission-to-share forms there, or to her home address, where I am looking after her house cat (we have had mix ups before, B-- Ward did not forward letters from the Trust for several weeks).
I am concerned that if I make this a formal complaint against Dr D, that it will prejudice against J's care on H-- Ward, so I'm not sure what to do, and yet still I have no guarantees that J will be kept safe when she is in crisis.
Again, I must stress, J seems to want to keep Dr D as her consultant, due to her pharmaceutical knowledge, but I believe the basis of this all-or-nothing-free-to-leave care plan needs changing. If this remains in place, I genuinely believe that J will die whilst being either in the care of the Bradgate Unit, or immediately after she has been discharged. Please help me prevent this.
(my name).
(for details see above)
Monday 9 February 2015
Mental health in the NHS: 'My son wanted to die; we begged for help but there was none' (Telegraph 7.2.15)
Mental health in the NHS: 'My son wanted to die; we begged for help but there was none'
A fairly upsetting article.
Quote from Sane charity:
“The psychiatric system is in meltdown due to the long-term relentless agenda to close psychiatric beds to save costs and treat everyone, however severely disturbed or in crisis, under the care of already overstretched and demoralised community home- treatment teams,” says Marjorie Wallace, chief executive of the mental health charity Sane. “It is no coincidence that the suicide rate has more than doubled for patients being treated by these teams in the last few years. At Sane, we witness daily the impact of the failures of the psychiatric services on patients, families and front-line mental-health professionals. In many places, it has led to a situation which is both cruel and inhumane, with unnecessary suffering on all sides.”
This tore me up a little:
"... a health worker told Mrs Jones she thought Matthew was “playing games”. ... “A few days later, my little boy was dead,” "
Friday 6 February 2015
The route J took to reach the busy main road
Thursday 5 February 2015
J's testimony regarding yesterday's near miss at the Bradgate Unit
J keeps notes online in passworded area in a forum. This is what she wrote last night about her suicide attempt after being told she could leave the ward. Names have been omitted.
"Not entirely sure what happened today - tried to leave the ward - was distraught at being stopped (it's a locked ward) - sat by the door for nearly 2 hours with staff taking alternative route on and off ward via a meeting room. Dr D__ (my consultant) was teaching and wasn't going to be free til 4:30pm. Another doctor (called S__) spent ages read my notes and him and the lovely ward matron J__ talked to me in the meeting room after a while (Will had arrived to visit me by then so was also present). After lots of talking, none of which I can now remember, Dr D__ (who had arrived) said she felt it would be counter-productive to section me and I must make the decision to stay or go by myself. Of course, that is what I had been waiting for - in my head she had just said "you can go" - I asked them to unlock the door, I vaguely remember something being said about packing my stuff and I said none of it mattered, then I walked off the ward, by chance, got through security doors when other people with pass cards went through them, got out to reception and left the building. Suddenly realised Dr D was a few paces behind me, as was matron J__ and Will. Apparently the police had been called, not sure by who or what they had been told. I just kept pushing forward, determined and freezing cold (only wearing slippers and seclusion gown). At the main road, the A50, the traffic was busy. Dr D stood a metre or two into the road, waving cars to go into the next lane. Will and Jo were holding me, making me stay on the pavement, then out of nowhere another couple of nurses from another ward turned up and helped form a human barrier in front of me. Dr D called the police again, and then they turned up. I was so cold and confused and exhausted and couldn't see any other thing to do, than to let Will and the police walk me slowly to their car and put me in the back (2 policemen, 1 policewoman). Dr D and J__ and the other nurses and police woman went back into the hospital through the gap in the fence/shortcut while the two policemen drove me and Will further down the road to the main hospital entrance and through the grounds to the Bradgate reception. I sat down, Will stayed with me, J__ went to find me a wheelchair, and the police seemed to be having some kind of argument with Dr D although I don't know what about, I felt sort of in shock. I still do."
"N__, one of my named nurses, is in charge of the night shift and she came to see me in my room, to talk and give me night time meds. I cried and kept apologising, and she kept saying there were no need for any sorrys, and she was relieved to see me alive. She also said it IS possible to recover from this level of depression, and she's not giving up on me, and I will not be hurt in any way on her watch. Then she supervised me making a cup of tea (not allowed in patients' kitchen without a nurse present after my attempted ligature suicide with j-cloths stolen from there). Then, lastly, she said if I need her at all, she is here for me, just go and tell her. "
She tries to kill herself on the road outside the Bradgate Mental Health Unit -a near miss
Apparently, with regards to J's risk, the revised care plan is meaningless. Repeatedly the doctors have asserted that J is free to leave the ward and that they will not stop her, but by doing so she is walking away from agreed treatment. J was frantic to leave yesterday, with the intention of getting to the main road to kill herself. The nurses wouldn't allow her to leave without talking to a doctor (which is appropriate and routine). We talked to a (junior) doctor but since the arrangement he described wasn't making sense it was agreed that the main doctor in charge J's care be called to the ward. Again this doctor asserted that J was in hospital and receiving care by choice but that by leaving she'd be walking away from care, and would not be stopped, but she also suggested that maybe J would like a walk or even leave to go home with perhaps the bed being retained (this is new). J has told the staff what she intends to do once she leaves the hospital, that she intends to go to the road and throw herself in traffic. She is wearing slippers and a seclusion gown, she even explains where her money is in her room to pay for the seclusion gown should she be killed wearing it. She asks to leave and they open a door for her. Dr D says something about going for a walk, but J is already walking at a pace down the corridor (sometimes she can't run due to an unsteadiness on feet, she had already fallen forward in the morning whilst trying to leave). We essentially give slow chase. Dr D is a few steps behind her and talking to her. I think at some point the junior doctor was told to ring the police. J gets near the road and we ask her to come back to the ward. We start to physically struggle with her. a couple of nurses who were nearby (perhaps on a break) come to help. We stand around her preventing access to the road. One wonders why the doctor is there at all, so willing was she for J not to be stopped. J is pushing against us and pleading. Eventually the police arrive and we are driven the long way around back to reception where J, totally exhausted, waits for a wheelchair to take her back to the ward. The police are trying to discuss something with the doctor, they are clearly not happy with something, I hear a phrase like "managed differently".
Today doctors and staff had a meeting with Jo, to which I was not present, but of many of the strange things said was that J put staff in danger and that Dr D was to be having a meeting with police to tell them not to respond or to treat J is if she was wasting police time if called when she is in crisis. They also seem to believe that I was considering legal action, I think I remember saying to the junior doctor that I would take legal action, but that there'd be not point because by then J would be dead. It's hard to focus on the positives of her treatment when I know she has been told off for being suicidal. J gets on well with the nurses on this ward and I get the impression that this doctor must have positive results otherwise why would she be so insistent on limiting the use of Sections (where a patient is held on the ward for their own safety). Again we have a sense that J is somehow supposed to just "get over" her suicidal feelings, or correct some sort of impulsiveness. I'm a bit numb and confused. For me the whole near-miss illustrated the difficulty I am having with this approach.
Whilst pushing J back, traffic behind me, the doctor had asked me to return to reception to check on whether or not the police were coming. Despite unsteadiness J is strong, but I'm stocky with good legs. The couple of female nurses weight for weight may not have been able to hold her back from a sudden surge to the road. Also I know that J hates the idea of me being there when she kills herself. I refuse and lend Dr D my phone. The really odd thing is that this all feels scary but routine for me, even if catastrophic things occur I know that life will be worse for me later if I hadn't been there, if only to be a witness. In a way I'm grateful that other people are seeing it. I think that I'm hoping somehow that this explains our position better. In the back of my mind I consider knocking Jo's legs from under her because once she's on the floor she might be safer, but the struggle itself is partly based on being a cushion if she falls, minimising injuries, maintaining her dignity. Technically we were off hospital property at this point. Maybe I'm thinking, is this part of the therapy? Does it help J to get so close to death to have some sort of epiphany? No, this was a mistake. They had screwed up, but still today, J is told that she has mental capacity and that her actions risked others (irony like some patients: those professionals were involved were there "voluntarily"). It's hard to know what's real and what is a type of psychological gamble on the part of the doctors.
I'm hoping to include a paragraph from J's point of view once she has given me permission to use it here.
Monday 2 February 2015
Update: The rewriting of care-plans. Speaking up and being listened to.
This is a follow up on a previous post where I said that J was being but into a position of risk because she was expected to simply "choose" not to kill herself and wouldn't be stopped by staff if she tried to leave the ward. A few days back we were presented with a care plan and were invited to add our own comments.
One of my requests was that where I didn't agree with statements that they could be rephrased in such a way that was positive and involving for J. We also pointed out that in order for J to agree to the care plan it had to be, well, agreeable, realistic and practical. We both sent back handwritten notes to the nurses' office on the ward. J again reinforced the notion that the template diagnosis of BPD, with all it's "cooperate or leave approach", was not helpful and that she was suffering from depression and anxiety (with OCD and Bulimia) and did not currently have the resilience and self esteem to repel the overpowering thoughts of suicide and worthlessness. I concentrated my response on overturning the premise that by not actively keeping J safe the ward staff created an incentive for her to act safe (hardly mentioning the negative message conveyed by implying a lack of responsibility on behalf of the 'Trust when it came to duty of care to vulnerable patients). I would be calling the police myself if she left the ward whilst suicidal, and pointed out that I did not believe that expressing a desire to leave and expressing a desire to kill herself constituted the "ability to make decisions" or "full mental capacity" because she was unable to entertain alternative scenarios (previous example of this: begging a policeman to take her to a motorway bridge because it was "logical" to let her die).
Anyhow. The nurses we were talking to on this occasion were pretty smart, inciteful and sympathetic to Jo's needs. Despite what the doctor had been suggesting, they reassured J that at the very least a duty doctor would be called to assess J if she tried to leave, and yes, maybe a temporary MHA Section would be used to keep her safe.
Another positive in all of this is that is that J and the doctor are prepared to change her medication. Previously J's anxiety and a string of "don't rock the boat" locum shrinks had made this difficult to implement in an effective or measured way. I'm pretty sure that the one thing the Bradgate Unit can just about do right is to monitor inpatients whilst changing drugs in a relatively secure environment. Certainly that's all they seem to do with some of the more "hyper" patients, who literally arrive shrieking and leave with quieter demeanors. One of the nurses has also been writing new sections in the care plan detailing ways they might be able to help with each aspect of J's condition (one-size-fits-all BPD umbrella aside), i.e. a paragraph and action points on anxiety, another on OCD and so on. The nurses seem to be finding time to talk one-to-one with her as well.
It's been a really tough couple of weeks, but J has been trying to be honest with staff about thoughts and plans she has about suicide and self harm. I won't go into details but there's been a couple of creative near-misses, which have led to J agreeing to have her room stripped, leaving her with an unfoldable "seclusion blanket" and she is currently wearing an indestructible "seclusion gown". The heating was broken in her room and another ward demanded the borrowed seclusion blanket back. J chose to be cold for a few hours, not trusting herself with normal blankets. It was returned and the other ward was admonished because J's legs still have odema which make them an "infection" issue. There are many odd institution-centric stories to tell just from the last handful of days, but thankful, in terms of day to day ward care it's so much better than some of our previous experiences at the Bradgate.
The doctor, who at times, has a very human side, hasn't challenged our alterations to the care plan and is praising J for recognizing and communicating her levels of risk. Also she is proud of J for committing to the plan to change medication during a 6 month voluntary stay.
J is very scared and still suicidal, but both of us, no matter how cynical or skeptical we are, seem to be happier with a plan from which we can add flexibility, if that makes sense? Like the first draft of the care plan - it's easier to change once it's in writing. J has been reassured that she will not be moved from her room. It's normal ward practice to swap and move patients around depending upon many factors which make perfect sense to nursing staff, but for many patients this can be almost traumatic and triggering emotionally. Even if this does happen to J, at least we know she can't be moved into a shared dormitory, because there are none on this ward.
Also, I'm surprised at how much the nurses and the doctor seem to be valuing my own input regarding her care. My name appears on the paperwork as the partner and carer and I'm seen as an important aspect of support in aiding her recovery. It's like a strange moment in a dream when you've been shouting forever and they actually turn and look directly at you, and stranger still, they are listening. Again, unprecedented!
(Posting this now, may return to edit later) ;)
NHS mental health care ‘pushed to breaking point by lack of beds’ (The Guardian 01.02.15)
NHS mental health care ‘pushed to breaking point by lack of beds’ The Guardian 1st February 2015
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