Patient safety

Day 348

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If anyone you know came to you and said,

“For the last few weeks I have noticed that nothing gives me any pleasure; I don’t feel interested in anything; I feel quite hopeless and I sleep all the time. Some days I can’t sleep at all and feel terribly restless and fidgety; I feel wretched about myself all the time and hardly feel like eating anything. I feel really tired and can hardly focus on anything. This has been getting worse for a few weeks but for the last 2 weeks, almost everyday the thought has occurred to me that I would be better off dead or hurting myself in some way. All these things have made it extremely difficult for me to do my work, take care of things at home or get along with other people.”, what would you think?

They are suffering deeply.

This is what a PHQ-9 score of 27/27 looks like.
This day last year, my son’s score was 27/27.
It had been 19/27 two weeks prior but had since risen.
I had noted the deterioration in his state of mind.
The words my son could not utter, he indicated on paper.
He was suffering deeply but sadly his suffering was not acknowledged by the professionals who we trusted to care for him.

If clinical judgement had been astute enough, we would have picked up on it and possibly turned it around – escalated care, reviewed medications, reviewed dosages, taken him to A&E.

If a patient with diabetes had a dangerously low blood sugar or another one with Hypertension had a sky rocketing blood pressure, would we just ignore it?

The investigation report mentions the PHQ-9 test as a ‘blunt instrument’. If that is the case, why is it used so widely? Why is it a well-recognized monitoring tool for patients with depression? How can it be ignored when a patient has the highest possible scores?

A baseball bat is a blunt instrument. But it has its uses. It can take a team to victory and crack a skull.

In the light of what I know now, it is not surprising that my son died of severe depression. In fact, it is surprising that he hung on for as long as he did.

Just because the patient is sitting and talking to us and there are no lumps and bumps, no obvious bleeding or pain, does not mean they are not suffering. They are slowly dying in front of our eyes. Their suffering is so unbearable that they will do anything to get rid of it. They are ashamed of it and can’t bring themselves to talk about the extent of it.

We need to learn to pick up on subtle signs.

When it comes to suicide, prevention is the only cure.

Day 339

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In a special little box highlighted in a greyish shade of blue the BNF (British National Formulary) says:

“The balance of risks and benefits for the treatment of depressive illness in individuals under 18 years is considered unfavourable for the SSRIs citalopram. escitalopram, paroxetine, sertraline, mirtazapine and venlafaxine. Clinical trials have failed to show efficacy and have shown an increase in harmful outcomes. However, it is recognized that specialists may sometimes decide to use these drugs in response to individual clinical needs; children and adolescents should be monitored carefully for suicidal behavior, self-harm and hostility, particularly at the beginning of treatment.”

This has been known for 10 years.

GlaxoSmithKlien came under heavy criticism when they were accused of ‘concealing’ important information from the public at the risk of harm to patients in the US.

In the UK, criminal action was taken against GSK and these medications were labeled as ‘suicide pills’.

Adolescent brain development studies have shown that the structure of the brain continues to change from the teens till early twenties before it assumes adult form.

In different countries, the definition of ‘adolescence’ differs. In America, consumption of alcohol is illegal below 21 whereas in the UK it is illegal under 18. In a medical setting, does ‘under 18’ mean that if the patient is a few days or months over, the rule does not apply to them?

My son was ‘around 18’, at the beginning of treatment, not monitored carefully and not under specialist care. This side effect of the medication that he was taking was not mentioned, leave alone ‘emphasised’ to me. No safety plan was put in place.

Could the choice of medication be responsible for what happened?

Or was it the way it was used that contributed to it?

Questions, questions and more questions.

The report of the joint investigation between the Mental Health services and NHS England is delayed again. They are also probably grappling with many questions. The Coroner’s Inquest is in less than 2 weeks.

Let’s see if we can find any answers.

Day 333

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A young nurse approached me and said “I just wanted to thank you for writing that article. I was not sure but now I know exactly what I need to do.” We stood hugging each other for a while in the hospital corridor this morning. I felt grateful for that moment. Her heartfelt gratitude brought tears to my eyes.

The response to the article makes me feel as though people have been waiting to hear more about mental illness and suicide. They have been like unacknowledged entities that exist amongst us silently. Or maybe we have been deaf-mute so far and now are ready to speak and listen. It is about time; already too late for some of us.

Last week I met a young doctor whose wife is near the end of her GP training. He told me that she has not spent any dedicated time in psychiatry during the 3 years of her training. Nothing at all. This is still happening. 1 in 4 patients attending a GP surgery present with a problem which has a direct or indirect bearing on their state of mind.

CPR (Cardio Pulmonary Resuscitation) is part of mandatory training for all doctors because it saves lives. But Suicide Prevention is not. Does that not save lives?

Those that speak out tend to be those who have been most affected by mental illness and suicide. That something good comes of their/our suffering and loss is but a small consolation but perhaps it was always this way:

Like to a ship that storms urge on its course,
By its own trials our soul is surer made.
The very things that make the voyage worse
Do make it better; its peril is its aid.
And, as the storm drives from the storm, our heart
Within the peril disimperilled grows;
A port is near the more from port we part –
The port whereto our driven direction goes.
If we reap knowledge to cross-profit, this
From storms we learn, when the storm’s height doth drive –
That the black presence of its violence is
The pushing promise of near far blue skies.
Learn we but how to have the pilot-skill,
And the storm’s very might shall mate our will.

– Fernando Pessoa

Day 326

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Prevention is better than cure.

Once it’s happened, suicide has no cure. In fact it can set off another wave of deep grief and vulnerability to further suicides.

Hence, prevention is everything.

The World Health Organisation has declared Thursday the 10th of September as World Suicide Prevention Day. It is an opportunity to raise awareness and break down stigma. Here are the main subheadings of the WHO document :

Reaching out

  • to those at risk of suicide
  • to those bereaved by suicide
  • to put people in touch with relevant services
  • to Suicide Prevention community.

Research suggests that 70 to 90 per cent of people who have made a lethal attempt, or died by suicide, were suffering from one or more unmanaged mental health issues – such as protracted depression or anxiety, bi-polarity, psychosis, and/or substance abuse. The presence of an unmanaged mental health issue is strongly associated with suicide.

Hence I would like to emphasise a few things here:

  1. Health-care services need to incorporate suicide prevention as a core component.
  1. Early identification and effective management of mental disorders and harmful use of alcohol and other drugs are key to ensuring that people receive the care they need.
  1. Close involvement, training and support for family and carers in the community.
  1. Education at every level – at schools, universities, religious communities, railway staff and general public.
  1. Give the issue of Suicide Prevention a place of prominence on the Public Health agenda as it is one of the biggest killers. Not limiting suicide prevention to writing documents that no one ever reads but making a proper awareness campaign which brings the issue to light in a way that everyone can see it – in the same way that road safety is addressed.
  1. Ensure that governments are fully engaged and every Local Authority has an effective Suicide Prevention Plan in place.
  1. Abolish internet chat rooms which help people with creative ideas on how to end their own lives.
  1. Stop under-recording the incidence of suicide at Coroner’s courts by not insisting on ‘criminal’ standard of proof as opposed to balance of probability.

While it may not be possible to prevent all suicides, let us do this like we mean it.

Every life lost through suicide is one too many.

Day 312

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Today I met this lovely little 70 years old lady at work. She had come in as a patient for a minor procedure under anaesthesia. She was well dressed and I couldn’t help but notice her hair. It was as though she had just walked out of a hair salon. It was beautifully styled. I could imagine her sitting with her rollers on under the hair dryer reading a magazine. I was impressed by the effort she had put into looking so good to come into a hospital for cancer surgery.

Instantly my mind flashed back to 2 days before Day 0. That day we had an appointment to see the GP. I had requested my son to shave as I gently woke him up reminding him of our planned visit. 10 minutes before we were to leave the house he came down the stairs. He had not shaved. I sent him right back and insisted he shave even if it meant we were a few minutes late. He really didn’t want to but he did. (Now I know how terribly difficult it must have been for him.) I was pleased to see him looking so neat and tidy.

The doctor’s report to the Coroner says – “He was well dressed, shaven and fresh. He made good eye contact. His speech was coherent and we had good rapport throughout. He said he had had a recent ‘set-back’. On being asked if he had suicidal thoughts he said yes but he had no plans. He said that he felt he would never recover from this illness. I reassured him that he would. He asked me how long it would take……. If other patients had returned to work….. There was nothing to indicate a relapse of psychotic features. The Citalopram was increased from 10mg to 20 mg daily.”

Despite the fact that during the previous visit 2 weeks prior, his PHQ9 (Patient Health Questionnaire 9, a monitoring tool for depression) score was 27/27, indicating the worst possible level of depression, the GP did not repeat the test on this visit. Was it because he looked ‘well dressed, shaven and fresh’? Would it have made any difference?

We will never know.

What we do know is that there is a huge need for education. Pills alone do not save lives.