‘Never let an aircraft take you where your brain didn’t get to five minutes earlier’ – this is a commonly understood concept amongst pilots.
While none of us can predict the future, the ability to anticipate problems that might arise given a particular set of circumstances is a basic requirement for many high risk jobs such as fire fighting, policing, armed combat and medicine. Doctors do have a licence to kill and they inadvertently use it when they can’t or don’t anticipate problems. Working backwards, if we don’t think the worst might happen, we don’t actively look for it and definitely don’t plan for it. Before we know it, it’s too late and the adverse outcome is inevitable.
Four days into it’s maiden voyage, the largest passenger liner of its time, the Titanic sank. It received six warnings of sea ice on 14 April 1912 but continued travelling near her maximum speed when her lookouts sighted an iceberg in its path. Unable to turn quickly enough, the ship suffered a killer blow and slowly sank over the early hours of 15th April. 1635 of the 2224 people on board died. The vast majority of the crew were not trained sailors but were either engineers, firemen, or stokers, responsible for looking after the engines or stewards and galley staff, responsible for the passengers. They were taken on at Southampton on short notice and had not had time to familiarise themselves with the ship. Knowing what we know now, is it surprising that the ship sank?
Saagar gave us warnings but we didn’t pick them up. Shouldn’t alarm bells be ringing nice and loud when a young man with a recent diagnosis of a mental illness is discharged in a hurry from Psychiatric services and he scores 27/27 on his PHQ-9? Whose responsibility is it to join up the dots?
When a plane goes down, the pilot goes down with it. When a patient dies, often nothing happens to anyone else. There is no black box. Tracks get covered, mothers over-react, things get forgotten and life goes on….
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.
What people do may be a better marker of depression than how people say they are feeling. Behavior can be objectively measured using mobile phones. It is an active sensing and prediction platform to identify behavior changes when individuals suffer from common colds, influenza, fever, stress and depression.
Studies have found a strong relationship between location (using GPS) and clinical PHQ-9 scores. The daily pattern, variability and extent of communications can also be analysed to give valuable clues to changing trends in activity. It is possible to monitor depression passively using phone sensor data. This has significant public health implications. Most people are unwilling to answer questions repeatedly over long periods of time, while passive monitoring could improve the management of depression in populations, allowing at risk patients to be treated more quickly as symptoms emerge or monitoring patients’ responses during treatment.
The efficacy of smartphone sensors and self reporting for mental health care has not been proven yet and remains a very important research question in the pervasive health community.
2 billion people already carry their smartphone with them most of the time. Even the cheaper models have sensors that can track movement and activity, generating data to provide insights into our wellbeing.
StayClose is a free family care app, powered by Touchkin’s predictive care platform. The app helps families care for loved ones while being afar by enabling them to know how they are, without having to ask. They can also share a touch or video moment, or do something to help, like send a ride to take them to the doctor.
For example, when a person is depressed, their phone is likely to show more time spent at home, unusually low activity, changes in communication or sleep patterns. It is possible for a machine learning engine to learn anyone’s phone’s normal sensor patterns and generate alerts if unusual activity indicates any health issues.
I look forward to collaborating with Touchkin for a few pilot studies in London.
Well, the most important thing is to keep one’s prejudices aside. It is also the most difficult. Ask them how they feel and listen with empathy.
Put no blame on them so they don’t feel guilty about it. Respond as calmly as you can and try not to appear shocked or angry. Don’t be dismissive. Self-harm could be an important warning sign.
Perform first aid and accompany the person to A&E or the GP as appropriate.
Ask directly about suicidal thoughts.
If they share thoughts of suicide, continue listening and ask open-ended questions.
Stay with them.
Tell them about the treatments and support available such as school nurses and CAMHS for the young and clinical psychologists, psychiatrists and counsellors in general.
Introduce them to ways in which they can help themselves: relevant books and websites; keeping a mood diary to monitor thoughts and feelings; regular exercise and healthy eating; reducing caffeine; getting support from friends and family; identifying enjoyable activities and finding ways of spending time doing those; identifying local support groups and addressing underlying mental health problems.
Saagar’s discharge letter from psychiatric services said – “No history of self harm.” They were wrong. On questioning they said that it was because he had never presented to A&E having harmed himself. But that is not a criterion. I don’t know if he was ever specifically asked about it or whether he misled them. He had prominent burn marks on his left forearm that could easily be picked up by trained eyes. When I asked him about it he made up a story to assuage my worries and made nothing of it.
I didn’t pick up the seriousness of it and sadly, we never spoke about it.
Andrew Kirkman was the same age as Saagar. He was a second year physics and philosophy student at Oxford. He ended his life in December 2013. Earlier that week he had seen the college doctor who had prescribed antidepressants for him. His parents had no knowledge of his illness.
Andrew’s mother, Wendy Kirkman has been actively campaigning for a directive that makes it possible for university doctors to inform parents of their children’s mental illness if they are at all concerned. She hopes this would save the lives of other students. “People seem to be frozen into inaction by the fear of disclosing information to the parents of students who are over 18, when they have always had the legal right and perhaps obligation to do so anyway.”
Dr Geoff Payne has issued new guidelines advising university doctors to contact parents if concerned for a students’ mental health.
The argument against this guideline is that merely telling the parents doesn’t fix the problem. That is true. However parents can provide additional support. Close monitoring of such cases and intensive talking therapies also have a very important role. Non-disclosure by itself is not a problem but it does translate to further lack of support in a system that has long waiting lists and inadequate capacity to provide optimal care for patients in need.
The other argument against it is student’s right to privacy.
Can the right to privacy be more important than the right to life?
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.
Daksha Emson was a young psychiatrist who had been diagnosed with Bipolar disorder when she was a teenager. When she got married, she wanted to have babies hence she stopped her medications.
She and her husband were lucky. They were blessed with a little girl in June 2000. They called her Freya. On the 9th of October 2000, Daksha ended two lives – her own and Freya’s.
The investigation report highlighted a few things :
– Failure of professionals to communicate effectively and to co-ordinate care appropriately contributed to the adverse outcome in this case – no liaison between psychiatry and obstetric services.
– Care Plan was not generated as she had informal consultations with her psychiatrist for fear of being stigmatised by her colleagues.
– A ‘Closed loop’ of care was not established for her. Although she had a Community Psychiatric nurse, she was not being closely monitored and links with other members of the multidisciplinary team were not established.
– The nature of Daksha’s illness could have been predicted if her ‘relapse signature’ (collection of warning signs) had been identified. It wasn’t.
Tutors and staff at universities struggle with the issue of confidentiality with regards to their students who are suffering with mental distress. While they are not trained counselors, they have the best interest of their students in mind. Yet, they are not allowed to take the parents of these students in confidence in the name of confidentiality.
Confidentiality is a foundational ethical standard for health professionals. It is the ethical duty to fulfill the promise that client information received during therapy will not be disclosed without authorization. It becomes a legal concern if broken, whether intentionally or not.
What if not breaking confidentiality leads to harm?
There are exceptions.
Confidentiality does not apply when disclosure is required to prevent clear and imminent danger to the client.
Protecting the client from harm must supercede the harm to the relationship that may happen due to a breach of confidentiality.
BACP (British Association for Counselling & Psychotherapy) Ethical Framework says:
“Situations in which clients pose a risk of causing serious harm to themselves or others are particularly challenging for the practitioner. These are situations in which the practitioner should be alert to the possibility of conflicting responsibilities between those concerning their client, other people who may be significantly affected, and society generally. Resolving conflicting responsibilities may require due consideration of the context in which the service is being provided. Consultation with a supervisor or experienced practitioner is strongly recommended, whenever this would not cause undue delay. In all cases, the aim should be to ensure for the client a good quality of care that is as respectful of the client’s capacity for self-determination and their trust as circumstances permit.”
The GMC reiterates the importance of confidentiality in good medical practice but does not talk of suicide in particular.
Courts usually consider two fundamental issues:
did the professional adequately assess the likelihood that a patient was suicidal?
if an identifiable risk of harm was determined, did the professional take sufficient precautions to prevent suicide?
In general, the therapist is protected from liability if they have conscientiously performed and documented a thorough evaluation, followed by carefully considered, appropriate interventions.
Early diagnosis and treatment of mental illness is key for better outcomes. Hence the staff at schools and universities should be equipped with skills and knowledge to identify such illness in students. They should be empowered to get appropriate help for them at the earliest.
In case of disclosure of severe suicidal ideation, the safety of the ‘at risk’ person should be the only concern.
UK has the highest rate of self-harm in Europe.
About 1 in 10 young people have self harmed.
It is nearly 3 times more common in women than men.
The highest number of calls made to Childline are from 12 year old kids self harming.
At least half the people who end their own lives have a history of self harm.
Around 200,000 episodes of self harm present to hospitals per year.
Many people who self harm do not seek help. Hence they are not reported or recorded.
What Self harm is not :
-Attention seeking behavior.
-A selfish act
-Done for pleasure
-A group or sub-culture activity
-A copy-cat response
Why is it done?
A release or distraction from emotional distress.
An expression of anguish.
An act of survival – a way to postpone suicide.
A form of self-punishment for feeling ‘bad’ or ‘dirty’.
A way of feeling’in control’
To feel real or alive if they have been feeling numb.
Difficulties in problem-solving
Difficulty coping with anger
Difficulty dealing with sexuality.
What to do if someone is found self-harming?
Stay with the young person and if necessary, take them to A&E.
‘Dying from Clear skin’ is a BBC documentary on Jesse Jones, a teenager dealing with acne like many others one might think. But he ended up taking his own life. Elements of low self esteem and bullying cannot be separated from the issue of acne. Jack Bowlby, a 16 year old from Wantage in Oxfordshire, killed himself at Cheltenham College. His inquest was told he experienced “dark thoughts and violent mood swings” after taking Roaccutane. Jon Medland, a medical student from Devon did the same after 3 weeks of starting the same medication.
Accutane (Isotretinoin) is a medicine used for treatment of acne.
Although it’s main desired effect is on the oil glands in the skin, it works on the whole body. Side effects are numerous and widespread, and affect at least 8 out of 10 patients. Side effects are most often mild to moderate and reversible, but in some cases can be severe or long-term. Accutane can cause severe birth defects if taken during pregnancy.
In reduces blood flow to the brain, causing headaches and depression as well as hearing and visual impairment.
I am no dermatologist but in my experience as a patient and a carer, doctors are not very good at telling us the side effects of the medicines they might start us on.
Parents have been noticing the connection between suicide and Roaccutane and lobbying against the drug for the past few years.
In a statement, Roche said: “Whilst no definitive cause and effect relationship has been established to directly link mood swings and depression with the drug, there have been rare reports, amongst both those taking Roaccutane and acne sufferers in general.” Figures show one in 10,000 people will experience serious side-effects. More than half a million people all over the world have been prescribed this potentially lethal medicine.