”No history of self harm” said the discharge summary from the Home treatment team to the GP. This sentence was one amongst many on the four page long letter.
Saagar was seen by at least 3 psychiatrists – 2 senior trainees and one Consultant and they all missed it. Did they ask him and he didn’t tell them the truth or was it an omission? The scars could easily be seen on his left forearm. They were clearly visible. Did they find the scars and questioned him about them? Did he make up a convincing story for them as he did for me? Or were they missed altogether? No one asked me about his history of self harm. He was mentally ill at the time and I don’t think I was.
At the Coroner’s inquest when this question came up, the psychiatric team said that the remark was made because Saagar never presented to the Emergency department with self-inflicted injuries. Is that a valid criterion?
Self harm is a personal and often a very private act. Given it is an important clue to the extent of a person’s emotional suffering, we as carers and professionals cannot afford to miss it.
“The only antidote to mental suffering is physical pain.”
– Karl Marx
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.”
Really? Is this protectionism or is it a reflection of a deeper level of ignorance within the medical community than I thought?
Am I the one who’s crazy? Imagining things? Over-reacting? Making false judgements just because I am grieving?
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.
The psychiatrists assumed that they should not speak to me about my son’s illness because he was antagonistic towards me during his manic phase, the time when they diagnosed him with Bipolar Affective Disorder. They sent him home, to live with me.
I assumed that they would tell me if there was something really serious that I should know, like the diagnosis, the trajectory of the illness being unpredictable and the mortality rate being higher than many cancers.
The psychiatrists assumed that the GP would be able to figure out the diagnosis from the Discharge Summary written by them.
The GP assumed that they would tell him more clearly and emphatically if there was something as serious as Bipolar Disorder.
I assumed that the GP would tell me that I was living with and looking after someone who had been having thoughts of ending their life almost on a daily basis. He prescribed some drugs and sent him home with me.
They all assumed that my ex-husband and I were educated people and would find out all the things that parents should know about their adult child’s illness.
I assumed that my son would say something to me if he was really struggling.
Everyone assumed he would get better. He assumed he never would.
By midmorning I had replayed yesterdays proceedings in my head a few times over. I could feel the anger rise inside me every minute and by afternoon it was an absolute torrent. The assimilation into my system of the facts revealed at the inquest resulted in feelings of absolute pointlessness and hopelessness. Nothing is ever going to change. One of his treating doctors said it in so many words, “Suicide is unpredictable and unpreventable”. I felt furious at the people who had allowed my son to suffer for weeks and weeks before he gave up on everything. He wanted to live. He followed every instruction given to him. He wanted to get better. He communicated how he felt the best he could. No one got it!
Luckily I had an appointment to see my homeopath this afternoon. It was a lifesaver. She was willing to listen to me and give me the space I desperately needed to express that terrible rage. She understood. She was there for me in body, mind and heart. After spending an hour with her, I felt relatively unburdened.
Allopathy doesn’t allow for that kind of therapy. It is defensive and supposedly “evidence based”, dry and prescriptive. It undermines other forms of treatment that offer the compassion that it is incapable of. I am sure there is no ‘scientific’ explanation why my arthritis is flaring up. Just as there is no ‘scientific’ explanation why my son died.
Whatever the inquest finds, I still have to work my way to being ok with settling for lighting a candle in front of my beautiful son’s picture every evening for the rest of my life.
A young man with floppy blonde hair sat next to me taking notes frantically. He had a massive folder on his desk. When I looked carefully at the writing on the spine of the folder, it read, “Master File Dr GP (Mr SN – Deceased)”
I sat in the courtroom looking at that label for a long time, thinking once again about the drama of life – a room full of people looking really solemn discussing the nitty-gritty of a young man having ended his life. For a while, I couldn’t hear any sounds but I could see lips moving and heads nodding. It was surreal. Once again I was looking in from the outside while sitting in the room. Was it me or was it him?
It was a gentle and compassionate process despite which the day felt very long and exhausting! A few glaring facts came into light – it was not clear to the GP that this patient had been discharged to him with the diagnosis of Bipolar Disorder. Apparently the discharge summary only made a passing remark on “Royal College of Physicians leaflet on Bipolar Affective disorder was given to the patient” without specifying Bipolar as the working diagnosis.
The presence of 3 lawyers in the room made the atmosphere quite tense and defensive but underneath that exterior, I could see the humanity and fragility of all concerned. At one level, I know that it is really important to examine each detail closely to stop this from happening again but at another I feel like there is no point. It’s too late for us anyway. Every new fact is painful. I know it’s selfish to think like that. But I am selfish. I would like something in return for going through all this pain but there is nothing at the end of it, if it ever ends.
It’s not over yet. Part 2 of the inquest will be in mid-november. Well. We are where we are.
“Once again, we have found the same shortcomings as have been discovered in previous inquests related with suicide. The story is different but the themes are the same – various parts of the NHS not talking to each other, risk of suicide not being assessed properly and safety plans not put in place, training in mental health for GPs being inadequate, support for families being poor and follow-up after discharge from specialist services being completely not pro-active. Same things …. again and again.
Clearly, the findings from previous inquests have had minimal bearing on practice so far. Will this one be any different? Do we have the time, money or will to look after patients with mental ill health properly? Does it really matter to us as a society, as a country?
Given that suicide kills more young people than AIDS, road traffic accidents and violent crime put together, we have a long way to go. Let’s wake up and educate ourselves. Let us demand better care for ourselves and our loved ones. In the case of suicide, prevention is cure. If not prevented, it is too late, too final and too painful.
We all matter. Each one of us.
To quote Sir Liam Donaldson from 10 years ago –
“To err is human.
To cover up is unforgiveable.
To refuse to learn a lesson is inexcusable.”
The Coroner’s inquest takes place on the 2nd of October, exactly 2 weeks short of his first death anniversary.
2nd October also happens to be a national holiday in India to honour Mahatma Gandhi’s birthday. He is one of my heroes, a man who stood for truth and non-violence.
Until today I have somehow been able to push the imminent inquest to the back of my mind but suddenly I am aware that it is less than 36 hours away. I trawled the internet this morning to gain an insight into what the process had been like for other people. I watched a few videos and found that it was very different for everyone.
I don’t know what to expect of the process, of others and of myself. I suppose that is a good place to be. What will be will be. I have been preparing for this day subconsciously since Day 0. This will be an opportunity to really be a “witness” in more ways than one.
Whatever happens, my son will not be coming back at the end of it. I will probably relive the entire experience in all its details all over again. That will be a familiar process as I have done it countless times already. But this time there will be other people in the room, participating in the conversation. That will be strange but I am open to it.
Somehow, the upcoming inquest is currently occupying a large part of my brain. My nervous system feels jangled. The butterflies in my stomach are fluttering really hard and my limbs feel week.
It’s not about my son or me anymore. It’s about learning meaningful lessons and bringing them into practice. It’s about acknowledging the tragedy that is suicide, not just for affected families but for the whole world. It’s about being aware of and sensitive to our own and other people’s suffering. It’s about never letting anyone suffer alone.