Taking Mental Health Seriously

Each time we consider a new 'suicide case' we know what failings to look for and the far reaching impact on the family left behind.

We see the same mistakes by the NHS and their private partners. Whilst researching another unnecessary death I came across a Sunday Times article highlighting the plight of 3 families separately claiming The Priory Hospital had contributed to the death of their loved ones.

There is no doubt that anyone seeking treatment, public or private for mental health is vulnerable and already suffering with a problem which requires treatment.

Each case I look at is fact specific, but common themes are identified.

• Steven Bancroft, 49, millionaire business man killed himself at Roehampton, London in December 2015.

• Gary Marvin was a father of 3 with a history of mental illness but was admitted to The Priory with recurrent depressive disorder. Having been assessed by a Consultant Psychiatrist he was assessed as 'malingering' to secure better housing. Despite ample evidence of psychosis it was not diagnosed. He went on to hang himself, having attempted to do the same weeks earlier. He was observed by staff every 15 minutes, but there were staff shortages and reliance on agency workers. Contrary to protocol there was no primary nursing charge of his care. He fashioned a noose from materials he had hidden in his room, mirroring what he had done before. The corner concluded neglect contributed to his death. The CQC found that The Priory had failed to take steps to reduce ligature risks.

• One month later, another preventable death was that of Murt Khan, 40 at The Priory Hospital, North London. He was placed in care on a Section in February 2018. After a 9 day stay at a cost of £6500 he was discharged as 'low' suicide risk. Only 3 days later he was found hanged in woodland.

• An adolescent, William Jordan, aged 16 hanged himself at the same facility. There were no regular checks and staff were found to have falsified the records to mask their failings after the death.

• The Times provided another example of a 53 year old man who jumped onto a railway track, having been allowed unaccompanied leave from The Priory in Bristol in 2018. Whilst in their care he became increasingly paranoid. He was struggling to hold a conversation and his cognitive functions were declining. Benny Thomas, father of 4 was an inpatient for 5 weeks. Despite his worsening symptoms he was not sectioned under the Mental Health Act. The family argue that he did not have capacity to consent for treatment and should not have been allowed to leave. The family will assert that his care plan did not allow him to leave unaccompanied.

Over the last 10 years The Priory has been investigated for substandard care in 30 cases.

Common themes

When someone presents with serious mental health issues, it is essential that a clear medical history is obtained, previous suicide attempts considered and an accurate risk assessment obtained. The effect of alcohol and continuity of appropriate medications are issues that I have often seen overlooked. All too often there are shortcomings. A family can often provide a realistic picture when it is in the best interest of the patient for them to do so.

Inappropriate discharge is a common theme to the cases we see. The families we speak to provide clear instructions that they could not cope and are inadequately supported in the community. We have run cases where husbands/wives and their partners have lost their jobs as the symptoms of their loved ones deteriorate. They simply cannot cope, battling with changes in behaviour, threats to self-harm and of suicide often with no sleep, and without training. Sometimes this is whilst struggling family responsibilities for children or their own ill health. The pressure is enormous.

In our litigated cases we have seen all of the above allegations arise.

As we come out of the pandemic and depression and anxiety are widely identified, we hope that the services that people rely on learn from their previous mistakes and the impact of mental health is prioritised.