Inquest Verdict After Another Mental Health Patient Dies

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.



An Inquest At Caernarfon, March 21 2017

Coroner Nicola Jones is currently holding the inquest on Josie James, a 15 year old who died after falling from the Menai Suspension Bridge in August 2015

Josie was discharged from the adolescent mental health unit at Abergele, despite ‘self-harming and having murderous thoughts’. Her mother Joy James was critical about aspects of her daughter’s care and said she wanted lessons learned. Mrs James said that Josie had started to change in 2012 when she said she could hear voices and became manic hyperactive and began self-harming. For 18 months, she was involved with the Child and Adolescent Mental Health Services (CAMHS). In 2015 Josie asked to be taken to hospital ‘because she didn’t feel safe’ and later became an inpatient at the unit in Abergele. But she said the family was then ‘stunned’ to be told that Josie would be discharged in four weeks, after she was judged as being ‘not suicidal nor at risk of self harm’. Mrs James said that the family had been told there would be no community support package and that she felt hopeless and helpless. She told Nicola Jones ‘As a family we have no interest in pointing the finger at any individual. We just want lessons to be learned’.

In such situations, despite allegations that the UK is full of hordes of ambulance-chasing patients pursuing frivolous compensation claims, it is an almost universal response of patients who have been harmed – or their families if a patient has died – to just want ‘lessons learned’ and for no-one else to suffer in the same way. However I suspect that Josie’s mother has no idea of how many unnecessary deaths of mental health patients there have been in north Wales and how callous and dishonest many of the region’s ‘mental health professionals’ are. Lessons are not being learned at all, no matter how many patients die and no matter how many complaints the Betsi receives about it’s mental health ‘services’. It is surely now time to point the finger at the individuals responsible – this is nothing short of a slaughter and the people responsible are sitting in well-paid jobs and are never even named in the media let alone held to account.

The inquest continues – I’ll be interested to see if yet another ‘narrative verdict’ is given, to ensure that yet another suicide is not actually recorded as such and therefore won’t show up in the region’s statistics…

Two More Deaths – December 21st 2016

The Daily Post online edition has just published reports of two more deaths in north Wales – one of these deaths was of a patient at the Hergest Unit and the other death also sounds as though it was probably that of a mental health patient as well.

The body of Michael Capper, who had been a patient at the Hergest Unit, was found in January of this year after he went missing at the end of 2015 Mr Capper’s inquest will take place in March 2017.

The Daily Post is also reporting on the death of 15 yr old Josie Rose James who fell from the Menai Suspension Bridge after leaving Abergele Hospital in August 2016 Josie’s inquest will also take place in March 2017.

In the cases of both deaths, it is mentioned that procedures and policies at the Betsi are being investigated.