Rose Polge. Rebecca Ovenden. Lauren Phillips.
All junior doctors. All deaths by suicide, in just over one year.
The only three publicly known. Total number not known.
Polge’s mother linked her suicide directly to conditions at work – exhaustion because of long hours, work related anxiety, despair at her future in medicine and the news of the imposition of a new contract on junior doctors.
This problem is not limited to the UK. Earlier this year, 4 deaths within 5 months in Australia propelled the launch of an urgent investigation into the problem. No such investigation in the UK. Indeed, the law here explicitly excludes suicide from the requirements to report work-related deaths. A GMC report in 2016 stated that the low morale amongst junior doctors was putting patients at risk. Signals of distress and a dangerous level of alienation are an indication that the system cannot simply go on as before.
At the 2017 BMA junior doctors’ conference, delegates gave the union a mandate to lobby for all suicides to be investigated formally by their employer, jointly with the GMC, Health Education England and the BMA.
In France, workplace suicides are a well-recognised entity.
Yes. Suicides are complex. There can be many contributory factors. But when there is clear evidence of a link to work pressures, that should be given appropriate attention.
A letter of recommendations addressed to SLaM, drawn up along with another mother, who lost her son, Simba, to suicide:
“The laws that govern the relationship between professionals and patients namely: the Data Protection Act (1998), the common law duty of confidentiality, and the Human Rights Act (1998) are all silent about the nature of the relationship between professionals and carers. This is because these laws regard each citizen as an autonomous agent capable of making decisions with regard to their own rights.
The Common Law Duty of Confidentiality in particular has been derived from the millennials-old Socratic oath taken by doctors, which is absolutist in its injunction stipulating that there is no condition under which doctor-patient confidentiality may be broken. The 21st century has witnessed a significant shift in the doctor –patient relationships as well as, increasingly, in the doctor-patient-carer relationships. The increasing need to care for patients outside of hospitals and within communities or in their homes, has necessitated a requirement for greater collaboration between professionals and carers.
Given the pivotal roles of carers in the management of service users, the professional’s duty to share information with carers is covered by the 7th Caldicott principle: the duty to share information can be as important as the duty to protect patient confidentiality.
As carers who have had first-hand experience of caring for loved ones, we set out below some recommendations which we believe will help professionals and carers in working more effectively together for the well-being of service users and carers.
Patients should be actively encouraged to nominate someone they trust in their care, right from the beginning. This practice should be so well engrained that the nominated person becomes an integral part of the process of care and recovery. It is also recognised that a patient may nominate a trusted person who is a friend to attend meetings instead of a family member, as the presence of the relative may inhibit frank and honest disclosures with professionals. For example, in CAMHS a young person may trust a friend to advocate for them more than they trust their parents. If this is the case, the right of the carer or next of kin to be kept informed of the care plan should also be respected, so that they are not left out of planning and can continue to care effectively.
This recommendation is particularly relevant if the service user lives with the carer.
2. At the time of diagnosis, accurate information about the nature of the illness and the choice of treatments should be given to the carers, in written and verbal form or on- line if such facility exists. They should be made aware of their rights as carers and encouraged to partner with health professionals in the care of the patient. They should also be given realistic information about the natural course and mortality of the illness. This may mean spending more time with patients and carers at consultations, and the need for additional support services.
3. Carers should be provided with the following:
– Diagnosis or working diagnosis of the psychiatric condition
– List of symptoms to look out for.
– A management plan.
– Choices of treatment.
– Possible side-effects of any medication.
– Possible roles for the carer in managing symptoms.
– Sources of support for the carer, for example pamphlets or online resources.
Professionals must remember the following when working with carers:
– To be more transparent in their communication with carers.
– To anticipate the carers need for information, providing necessary information about the nature of illness and available services even if the carer does not directly ask for this.
– To have empathy and willingness to engage carers and build a trusting relationship.
– To consider that carers may need practical support in order to be effective carers.
The carers must be educated and empowered with knowledge about the psychiatric condition. They should be made to feel involved in the process of care, especially if the patients are being cared for in the community. Crisis teams and early intervention teams should engage members of the family in the care package.
It needs to be understood that carers are a valuable resource, and must be listened to, as they spend more time with the patient than professionals do, and therefore will know them well. Even when service users instruct teams not to see their families, professionals should always meet with the families for collateral history, and especially if the family requests to be seen by a professional. Carers and friends know their relatives well enough to see early warning signs, and should be encouraged to share such information if necessary, in confidence with professionals especially if the service user is too ill to give consent because they are lacking in insight.
Carers’ perspectives should be part of the training curriculum for junior doctors and medical students wherever possible.
Patients should not be discharged from one team to another or from specialist care to primary care without arranging an early follow-up date. Given the risk of patients falling through cracks in the service following discharge, carers should be given adequate information about service structures and not merely told to go to the GP or the local AE in crisis situations.
Decision making around the timing of discharge should be properly scrutinised, as premature discharge could have disastrous consequences.
Discharge plans should include information for carers about the following:
-What are the warning signs to watch out for?
-What service number to call?
-How quickly one can expect help to arrive.
-Where to go in day/night time in a crisis.
GPs must also understand the importance of engaging with carers, listening to them, and sharing important information.
Community teams should engage patients and families in discharge planning. Where necessary, designing a crisis plan should be a joint enterprise between teams and patient and family. Carers should be involved in the design of the plan, and be given a copy of the finished document. Professionals must anticipate any problems with the patient and share them with carers at the time of discharge.
Organisational structures should be redesigned to address the problems brought on by the strict compartmentalisation of services. This can be a hindrance to the provision of safe and efficient patient care.
Mishaps and suicides should be investigated within a week, with the intention of learning lessons and preventing future serious incidences due to the same causes. Carers should be involved in this process, in order to hear the story from their point of view and arrive at real answers. Defensive investigations do not add to learning or patient safety. Contact with families must be at the earliest possible time following death or serious incidents. This is the time when families are most vulnerable and require information about their loved ones from those who were present. Legal considerations of blameworthiness should not prevent staff from empathetic consideration and communication with the bereaved families. Likewise, protracted legal processes should not be allowed to stop the trust from reaching out to bereaved families. Carers understand that staff may feel vulnerable following serious incidents but it should be understood that carers feel equally vulnerable and unlike professionals, may have no access to support networks at such times.
At Coroner’s inquests, the trust should send representatives who have a deep knowledge of the case and who will not hide behind jargon.
In 2004 the U.S. Food and Drug Administration issued a black-box warning against the use of all antidepressants in individuals up to 24 years old due to concerns about the increased risk of suicidal thoughts and behavior.
Depression often presents differently in children and adults. The very condition that the antidepressants are supposed to treat is made worse by their use in the young because their brains are still developing.
A meta-analysis of 34 RCTs published by Oxford University in the Lancet in August 2016 says that only one drug among all antidepressants is statistically better than placebo and that is Fluoxetine or Prozac. The lead author, Dr Andrea Cipriani claims no influence of the pharmaceutical industry on these findings.
Prozac has made hundreds of court appearances and billions of dollars have been paid out in compensation lawsuits.
‘The idea that it’s been a major step forward for Prozac to select serotonin only is just hypothesis,’ says Malcolm Lader, professor of clinical psychopharmacology at the Institute of Psychiatry. ‘There’s no science behind it.’ Some SSRI users have reported agitation and an inability to keep still, a preoccupation with violent, self-destructive fantasies and a feeling that ‘death would be welcome’. In Germany, Prozac was initially refused a licence after trials resulted in 16 attempted suicides, two of which were successful.
For mild depression, talking therapies are recommended. Young people with moderate to severe depression are often believed to need medication. They need frequent and close monitoring. However, there are huge variations in practice. It is easier to write out a prescription at a brief consultation rather than delve deep into details. As for the usefulness and safety of antidepressants, the jury is still out.
Saagar was on Citalopram for a few weeks before he died. The GP investigator said he should have been on Prozac but she didn’t write it down in her report. The representative of the Psychiatric hospital was a Clinical Psychologist. She said she could not comment on medications. The mud is watery.
Biggest cause of avoidable deaths in children and young people – Suicide and self-inflicted injuries
The Office of National Statistics published a report in 2015 saying that the single cause with the highest number of avoidable deaths in children and young people was suicide and self-inflicted injuries (14% or 206 deaths of all avoidable deaths in this age group).
Of the top five causes of avoidable deaths among children and young people, suicide and self- inflicted injuries was the only cause to see an increase since 2014 by 13% or 24 deaths.
Avoidable mortality accounted for 3 out of 10 deaths of children and young people (aged 0 to 19 years), nearly the same as in 2014. Males accounted for almost two-thirds (63%) of avoidable deaths in children and young people.
The other top causes each saw a decline since 2014, with accidental injuries, which was the leading cause in 2014, experiencing the largest decline of 8% or 15 deaths.
Key Points for London
The rate of avoidable mortality in London has increased to 210.4 deaths per 100,000 population from 204.6 in 2014. This is significantly lower than for England (222.9).
The South East, East of England and South West Regions have lower rates of avoidable mortality than London. The highest rate is in the North East (266.4).
As in all other regions, avoidable mortality rates in London are higher for males (274.0 deaths per 100,000 population) than for females (152.9). Rates have increased for males (from 259.9 in 2014) and slightly reduced for females (154.3 in 2014).
Most life assurance providers exclude suicide within first year of the policy.
A benefit scheme run by Utility Warehouse is called Bill Protector. It’s for Utility Warehouse customers, and basically between £2-9 per month added onto your premium. This gives cover for your bills should you lose your income due to illness, injury or redundancy. There is also an accidental death cover.
The illness cover excludes mental health. The basis of this is because it’s ‘hard to prove’. The attitude of the underwriters seems to be that people could go to their GP and simply say ‘I’m depressed’ when they’re not and be signed off work. This is in part due to an industry-wide attempt to combat insurance ‘fraud’.
It is interesting that mental health was covered until July 2016 and then they decided to write it out.
What annoys me most is that this is sold to customers as cover for bills in the event of illness, and then when they call to make a claim, they’re essentially told that their mental health difficulties don’t qualify as an illness – it’s the same old issue of perceptions and attitudes towards mental health. I think if there are going to be any restrictions like this, it should be made abundantly clear.
We as a society treat mental and physical health just the same. Don’t we?
Last September I started writing a case study on patient safety for an academic paper. For every sentence, it required evidence. Unfortunately, the level of evidence for some of the material is not high because of the nature of the subject. Secondly, research in mental illness is poorly funded in the UK.
I am reminded of a young friend who is looking for a job but she can’t find one as they require her to have experience which she cannot gain unless she has a job. A classic chicken and egg situation.
So, the deadline has been extended time and again and finally we are going to have another attempt at submitting it before the end of this month. The lowest level of evidence to be found is Level 5 – ‘Case series or studies with no control’.
Here is one that I am going to use to support my statement: “Almost everyone who is suicidal is ambivalent. They don’t necessarily want to die. They just want the pain to end.” Hopefully it will be accepted.
Kevin Hines is one of less than 1% of people to survive a jump from the Golden Gate bridge in a suicidal attempt. He is now a mental health advocate and works actively towards suicide prevention.
“The millisecond my hands left that rail, I thought, ‘what have I just done? I don’t want to die, God please save me’, and then I hit the water,” he said.
“You fall four seconds, you hit the water and get vacuum sucked down 70 or 80 ft – when I opened my eyes I was alive. “All I desperately wanted to do was survive – suicide experts call this being ‘shocked into reality’.”
More Vietnam veterans have died by suicide than were killed in Vietnam. According to the Veterans Administration, one veteran dies by suicide every hour in the USA.
‘The survivor is a disturber of peace. He is a bearer of ”unspeakable” things. About these he aims to speak, and in so doing he undermines, without intending to, the validity of existing norms. He is a genuine transgressor, and here he is made to feel real guilt. The world to which he appeals does not admit him, and since he has looked to this world as the source of moral order, he begins to doubt himself. And that is not the end, for now his guilt is doubled by betrayal– of himself, of his task, of his vow to the dead. The final guilt is not to bear witness. The survivor’s worst torment is not to be able to speak.’ – Terrence Des Pres in ‘The Survivor’.
”If the thing they were fighting for was important enough to die for then it was also important enough for them to be thinking about it in the last minutes of their lives. That stood to reason. Life is awfully important so if you’ve given it away you’d ought to think with all your mind in the last moments of your life about the thing you traded it for. So, did all those kids die thinking of democracy and freedom and liberty and honor and the safety of the home and the stars and strips forever? You’re goddamn right they didn’t.” – Dalton Trumbo in ‘Johnny got his gun.’.
Viktor E. Frankl said, ” Suffering ceases to be suffering when it has meaning.”
Meaningless violence gives birth to more meaningless violence. There are no winners. All sides loose.