After more than a year of Saagar’s death I could see that nothing at all had changed. Nothing was going to change. There is no power behind a Coroner’s inquest report, no legal, professional or financial implications for anyone concerned. Hence no lessons learnt.

I approached the GMC for help with the view that may be they will see things as they are and have more power to influence change but this is the letter I received from them today:

“In January 2016 documents regarding Saagar’s care were referred to a GMC Medical Case Examiner for review. I can confirm that the Case Examiner was specifically dealing with Dr GP and any issues surrounding his fitness to practise when they reviewed the documents. A decision was made by the Case Examiner that there was nothing contained within the documents which would call into question Dr GP’s fitness to practise and that as such the case should be closed with no further action.”

1. Really? Is this protectionism or is it a reflection of a deeper level of ignorance within the medical community than I thought?
2. Am I the one who’s crazy? Imagining things? Over-reacting? Making false judgements just because I am grieving?
3. The job at hand is clearly much harder than I thought it might be. I can teach children to ask for help. I can teach parents and teachers to identify signs of crisis and get professional help for them. They can take them to the GP. And then what?

The GP may ask them to fill out a PHQ-9 questionnaire. They may score 27/27. The GP might not discuss that with the parents. Not get anyone’s advise on the phone. Not refer them to a mental health specialist. They may send them home with a medicine that might worsen their suicidal ideation. They may also reassure them that they will get better.

That is like sending someone with terminal cancer home with the assurance that they will get better. That however would be unacceptable because cancer is a physical illness.

Severe depression can be invisible to the untrained eye. So, it’s ok for GPs to send young men with the greatest degree of depression home. Unquestionably.

‘Parity of esteem’ is a joke.