Communication gaps between teams, poor risk assessment, inadequate training for doctors and carers, poor discharge planning, absent safety planning, failure of proactive follow-up, no consultation with and support to families – these are the most commonly occurring themes from inquest reports on suicides for the last 15 years.
Yet, the story repeats itself again and again and yet again. Why is the rate of suicides amongst men rising when we have known for a long time what needs to be done? In 1982 the rate was 21.5 and by 2012 it was up to 25.9 every 100,000.
While mortality from serious ailments such as cancer, heart disease and AIDS has fallen dramatically over the last 30 years, that from suicide in men has risen. This is happening in our society because we allow it to happen. We as a collective consciousness need to find an honest answer for these questions within ourselves : What value does a person from low socio-economic background hold for us? What value does someone with mental illness hold for us? How much time and attention are we willing to give to people who are so utterly without hope that they end their own lives?
“You make a mistake only once”, I used to say to him. “If you do the same thing a second time it is your unwillingness to learn.” We as humans don’t learn anything till something is at stake. Do we have anything of value at stake here?
It appears 8 months was not long enough for the investigators of our case to prepare a report on what happened during the 10 week period of his illness. Hence the Coroner’s inquest has been delayed until further notice. We were informed today, 5 days before the day. Very disappointing!
The Chief Medical Officer then, Sir Liam Donaldson speaking at the launch of the World Alliance for Patient Safety in Washington DC in 2004 summed up the challenges of patient safety in this way: “To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.”
Words, words and more words.