I reported in a previous blog post ‘An Inquest At Caernarfon, March 21 2017’ that the inquest on Josie James was taking place. Josie was 15 when she fell to her death from the Menai Suspension Bridge and had just been released from the adolescent mental health unit at Abergele Hospital, prior to which she had been a patient of CAMHS (child and adolescent mental health service). Josie had been self-harming and had suicidal and ‘murderous’ thoughts. As I suspected she would, the coroner, Nicola Jones, has returned a narrative verdict – ‘because of her state of mind, it wasn’t clear that she intended to jump from the bridge’. Yet the inquest heard that Josie was taking posters down off her wall and had been saying goodbye to people before her death. Furthermore it was reported that a friend had tried to talk Josie out of jumping from the bridge when she called him on her mobile and told him that she was on the bridge and was going to jump off. That all sounds fairly decisive to me. So once more a mental health patient who killed themselves will not feature in the suicide statistics. And because she wasn’t in the ‘care’ of the mental health services when she died, Josie won’t feature in those statistics either.
However, the Betsi have admitted that despite Josie deciding to stop taking her anti-psychotic medication, a decision was made to discharge her a week before her death, after she was declared ‘not suicidal nor at risk of self harm’. Josie’s mother said that no community support package had been put in place and the family had ‘no idea what was happening’. Psychiatric nurse Kate Roberts confirmed there had been a lack of consultation and communication with the family throughout the final few months of her life. Psychologist Phillippa Thomas said: ‘The way she coped with people was problematic for her’ and said that she knew of an expert’s report which said Josie was having ‘murderous thoughts towards herself’ a week before Josie was discharged and added that it would have been better if her family had received that information. Consultant psychiatrist Dr Robin Glaze said it was ‘not unusual’ that Josie had starting cutting herself before being discharged, but she was also said to be ‘happy and cheerful’. He confirmed, however, that Josie’s care plan had not been signed off before her discharge and there was no emergency number available for her to call. CAHMS director Dr Peter Fore-Rees said: ‘Communication wasn’t clear. I think attempts were done but it wasn’t effective or clear. I think it’s completely clear that we need to improve’.
So it’s the usual story of service failure, inconsistent comments regarding the patient’s state of mental health and a sideswipe at the patient ie. the comment that the way Josie dealt with other people ‘was problematic for her’. It sounds to me as though it was the way that the mental health services dealt with Josie was the problem.
Josie’s family are pleading for the Betsi to ‘learn lessons’ and improve their care. There have been a lot of people asking for that for years now. As for the Betsi – well they are now going to set up a ‘user group’ made up of service users, their families and their clinicians, which will help them to listen and learn about how to make meaningful improvements’. The north Wales mental health services have been running ‘user groups’ for years to listen and make improvements’. Those ‘user groups’ have consisted of tame, powerless ‘users’ who did what they were told and exerted no influence at all, as described in previous blog posts. And anyway, the Betsi have just paid 1.5 million to CAIS to provide ‘service user involvement’ – the CAIS Board includes Lucille Hughes, a woman who concealed a paedophile ring, and her former partner, Dr Dafydd Alun Jones, who was sued for illegally imprisoning a woman in the North Wales Hospital Denbigh for a year – please see previous blogs about CAIS for further details. Neither of them have a track record of ‘listening to service users’.
I suspect that Josie’s family have no idea how many times the north Wales mental health services have made the same mistakes that have led to a patients death, every time promising that they will ‘listen to the users’ and ‘learn lessons’. These people are incapable of improving or learning lessons, they need to face prosecution for criminal negligence and be replaced by people who can actually deliver mental health care.