The inquest at the Coroner’s court is to be continued on Thursday, the 17^th of December 2015. It will be a dignified and detailed process as it was the last time. We will go over all the details once again.

This has happened many times before. The NICE guidelines will be looked at. All those concerned will do their best to say they did their best. The aim will be to make some useful recommendations and those will be made.

Yet again there will be lessons.

Will anyone follow them in the future?
Will it make any difference at all?
Will there be any lives saved?
Will it make people stop and think?
Will anything good come out of it?

I don’t know. I suspect not.
It has happened many times before.
We will not find anything that is not already well known.
What can be done to have a different outcome the next time?

I think if every health practitioner looked at a patient and approached them thus –
“What would I do if this person was my very own?”:
if the highest possible PHQ-9 score on a piece of paper meant “SUFFERING” rather than an unreliable piece of data; if picking up the phone for a bit of advise did not mean admitting incompetence;
if nothing but the best interest of the patient was the prime consideration while looking after them each and every time;
the correct course of action would be crystal clear.

Recommendations and guidelines can only be effective if they are backed by love and empathy.