Patient safety

Day 459

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The General Medical Council says,

‘Wherever possible, you should avoid providing medical care to anyone with whom you have a close personal relationship’, in Good Medical Practice for doctors.

The standards of treatment or care may be compromised where doctors provide care to members of their family. A number of reasons are suggested for this:

  1. Emotional involvement can lead to a lack of objectivity in clinical decision-making.
  2. Assessing family members’ condition and providing treatment outside a practice setting may also mean that family members do not receive the same standard of care as other patients.
  3. People who receive care both from a doctor who is a family member and from a separate GP may not develop effective relationships with their own GPs or other doctors and their records are likely to be incomplete.
  4. Doctors’ family members are entitled to confidential medical care; family members may withhold information which is vital to a diagnosis or management of a condition. This may be a particular problem for children and young people – but could be relevant to the care of anyone with a close emotional relationship with a doctor.
  5. Doctors may not feel able to ask sensitive questions or conduct intimate examinations on relatives.
  6. Family members may feel unable to refuse treatment or seek alternative approaches to the management of a condition. Questioning a recommendation or seeking a second opinion may be seen, by either party, as demonstrating a lack of trust.

Everytime I think back to the sequence of events that led up to Saagar’s death, I feel stupid. How could I have not known? I know for sure that many other parents feel the same. As parents we have complete lack of objectivity. I was so used to Saagar being fiercely independent and intelligent that it wasn’t anywhere in my consciousness as a possibility.

What would have made it come into my awareness? Someone I trusted would have to sit me down in a quiet room, look into my eyes and tell me this: “Bipolar Disorder is associated with very high mortality. It is a real possibility that your son may end his life,” at least 10 times. Even then, I am not sure I would get it ….

 

 

 

Day 450

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In the year 2000, John O’Callaghan, a 29-year-old Australian who became mentally ill after taking Lariam during a surfing trip to Indonesia, wrote in his suicide note: “Since [Lariam] first blew my brains apart… I have never been the same, always dazed and confused, always physically sick. I never thought this could happen to me. Sorry mum, dad.”

In 2001, 27 years old Malcolm Edge, an irish student was found hanging in a hotel room in Vietnam after suffering a paranoia attack apparently brought on by a combination of Lariam and alcohol.

In 2002 four US soldiers from Ft. Bragg were accused of killing their wives. Two of the men died by suicide. So many brutal crimes, so similar, so close in time – raised questions, and the army sent a team to investigate. One possible suspect was mefloquine (Lariam), an anti-malarial drug, routinely given to soldiers deployed overseas.

“It was confusion, it was disorientation, it was anxiety and panic attacks,” says Dr Paul Clarke, an infectious Disease specialist. “There were episodes in which people were clearly divorced from reality and indeed had unusual symptoms that could be described as psychotic.”

Lariam (generic name: Mefloquin) was invented by the US army. It is manufactured by Roche which constantly manipulates numbers and words to misinform doctors and public. It claimed that the incidence of psychiatric side effects was as small as 1:10,000. However Dr Clarke’s research showed that it was as high as 1:140.

Beware: Lariam can make you lose your mind.

 

 

 

 

 

Day 427

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It’s done.
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.

Good night.

Day 413

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This is Saagar.

SaagarBWs

If I knew that everyone taking care of him had done everything in their power to help him I would have felt a lot better. While it is very upsetting to see the gaps in knowledge and organization amongst medics, it is clear that there are areas that they don’t even know that they don’t know anything about. One of them is suicide prevention.

Cardio-Pulmonary Resuscitation(CPR) training is mandatory for all health care professionals because it saves lives. Shouldn’t Suicide Prevention Training be mandatory as well? We know it saves lives.

I heard a truly compassionate psychiatrist speak today, Dr Alys Cole-King. Her vast knowledge and passion about Suicide Prevention was truly inspiring. She is absolutely committed to the cause of Suicide Prevention and spends a lot of her time travelling around the UK working for the cause.

Connecting with People is an organisation set up by her and some of her friends to enable them to have a sizeable impact on reducing deaths by suicide.

I look forward to being able to help them in whatever way I can.

 

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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.

Postnatal Depression continues to be a major cause of death of young mothers. Joanne Bingley Memorial Foundation does a good job of de-stigmatising it and raising awareness.

Same old tragedies. Same old themes.