National report

On Wednesday 16 July I represented Leeds Community Healthcare NHS Trust at the National Confidential Inquiry into suicide and homicide by people with mental illness. The event took place at the Manchester Conference Centre and was opened by Niall Boyce, editor of The Lancet Psychiatry.

The first speaker was Stephen Habgood from Papyrus This was the sharing of the story of Stephens' son's death. It was titled ' All the Kings Horses'. When this gentleman spoke there was a total silence in the room as we heard the pain and loss suicide brings. Words from me to describe this story would be a very poor thing. The power of it struck me like lightning. What I can say it is that it was so right to start this event with these powerful and heart touching words. It set the centre and heart of what we were about to hear. I would like to use this space to thank Mr Habgood for his words and sharing. 

The second speaker was Professor Dame Sue Bailey, Consultant Child and Adolescent Forensic Psychiatrist at Greater Manchester West NHS Foundation Trust. This was an impacting speech. Professor Bailey drew from the Francis and Berwick reports to share her thoughts.  What I found so valuable were sentences which really struck and resonated with me. These statements don't need my commentary so I will record them as I scribbled them down. These are my summaries

          - one death - a ripple effect of thousands 
          - the need to listen to parents and families
          - the need for continual learning - all teach, all learn
          - prefix quality with safety. The two go together. If we get safety right quality will follow
         -  the need for intelligent kindness in healthcare
         -  quoting Bill Gates - 'It's fine to celebrate success but it is more important to heed the lessons of failure.'- the duty of candour

These may seem like truisms and obvious value statements. If however we all really lived and sourced them in our practice and services a real transformation could occur. 

The last speaker was Professor Louis Appleby, National Director for Health and Criminal Justice and Professor of Psychiatry at the University of Manchester.  Professor Appleby is Director of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. He presented the findings of the report. The findings can be found here. The presentation ended with recommendations. These included: 

       * suicide three days after hospital discharge should be regarded as a 'never event'
       * care planning needs to be careful and effective including for those who self-discharge 
       * adverse situations / events that precede admission should be addressed before discharge
       * the benefits of reducing length of stay in in patient stay should be balanced with risks and should not be an aim in itself
       * in intimate partner homicides, mental health services should play a full role in multi- agency work and case reviews. 
       * Crisis Resolution and Home Treatment might not be suitable for patients with too high risk or who do not have good family and other service support
       * economic factors should be recognised with patient suicides and support offered with housing, debt and employment.
       
There is here a real challenge for our mental health services and other care services. I would suggest it is even a bigger call than that. Three months ago I received a call at work that a friend of mine hadn't shown up at work. A visit by the police and his father to his flat the next day found him there. He had taken his life. This was someone who had a job he liked, lots of friends, a great career future and who did a lot of good to others. I and others still have no real answers as to why our friend took his life. He never had any contact with mental health services and as far as we know showed no signs to any of us of mental illness. The answer to this is bigger than any service. I think it lies in how we create cities, conversations and cultures where people can talk about their feelings and thoughts and where we can support people to find hope in the darkness they may be encountering. This report raises vital questions and recommendations for all us to work with.

John Walsh, York Street Practice