The facts have been established.
Not all, but a few important ones.
It would have taken a few weeks of deliberation to get all of them out in the open.
I was not looking forward to it and wanted to jump to the other side of it asap.
The inquest was once again conducted in an open and investigative manner. Everyone was given time to say what they wanted to.
The verdict was:
“Took his own life while of unstable mind.”
Contributory factors identified were:
- Poor communication with the family about Saagar’s illness, the seriousness of it and the side effects of the medications he was on.
- Poor discharge summary and handover from psychiatrists to the GP – diagnosis and warning signs for a referral back to the psychiatrists not clearly mentioned.
- Poor judgement on the part of the GP to have not sought specialist help for him on seeing his highest possible PHQ-9 score, possibly causing him to prescribe inappropriate medication which might have added to Saagar’s suicidal ideation.
All the things I have been going on about!
The one person that struck me most was the witness from SLaM (South London and Maudsley) Trust who was in-charge of patient pathways and improvement in services. He had been a nurse but now is a ‘manager’ of sorts. He uttered nothing but jargon, office-speak, absolute rubbish, completely devoid of any heart or clinical sense. He claimed to disseminate the lessons learnt through ‘business meetings’. I don’t understand how the two things are connected. That is the true face of modern NHS.
While the verdict was what I had hoped for, I don’t have much hope for change as the people responsible for improvement are nothing but pimps.
I feel completely scooped out, as if my insides have been hollowed out with a blunt knife. It’s time for some rest.
I’m so sorry I know exactly how you are feeling following the postmortem and my sympathy is with you.