David James West 24/08/85 – 20/10/2013 - PowerPoint Presentation

1. David James West 24/08/85 – 20/10/2013 28 years old

2. David James West born 24/08/1985. He was born 6 weeks premature, had foetal distress, traumatic birth, had forceps delivery and jaundice – I believe he had a brain injury at birth.Eldest of 4 children.Very difficult early years – IQ in top 1% of population – intellectually gifted, member of MENSA – Expelled from school aged 10. Special Educational Needs and difficulties. Left handed, had Dyspraxia, dyslexia and dysgraphia. Diagnosed with ADHD and given Ritalin.Was educated Monday to Friday at a special school and came home at weekends.Immature, lacking social skills and wanted instant results to his needs. Mismatch in his potential and what he achieved.

3. Drifted into drugs, became psychotic and had serious mental health problems – sectioned under Mental Health Act many times. Diagnosis varied. Lots of anti psychotic medication given which did not help him but was like a “cosh”Came to Hampshire because of physical and financial abuse and was cared for by Southern Health NHS.Engaged and disengaged when it suited him – moved around the area.Continued to take illegal drugs. His way of escaping from the world he lived in.Difficult life to lead – self harmed and self neglected. He was a vulnerable person.My son died of an overdose of drugs in October 2013.

4. What happenedCritical Incident Report completed by Southern HealthVery concerned by contents of reportThe Doctor simply wrote on his patient notes “Mental disorder due to multiple drug use. No underlying mental illness so he is responsible for the mental state he gets into when he takes drugs, just as substance abuser of Alcohol is. No role for AMH and he is toxic to such a service. Discharge from CCT. No letter.” As a direct result of this Doctor’s actions it meant my son was without medication, had no access to a GP or the Mental Health team for a period of about 10 weeks which left him in a dreadful mental state. Connor Sparrowhawk death – Justice for LB - http://justiceforlb.org/Later the Mazars report - https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2015/12/mazars-rep.pdf 1000 deaths were not investigated.

5. The complaints process – One year“Independent” investigation undertaken. Letter from Chief Executive of Trust Three days after letter from Chief Executive - Inquest: Coroner recorded death as being Death due to dependent misuse of drugs as a consequence of lifelong mental health problems. Reputational damage seemed more important to Southern Health than getting to the truthMy background

6. Complaints process PHSO reportWe partly uphold Mr West’s complaint.We have found failings in the care provided to David West. These include:failing to allocate a care coordinator failing to refer to Assertive Outreach or for a forensic assessmentnot updating Risk Assessments and Crisis, Relapse and Contingency Plans writing unprofessional and derogatory comments within medical recordsdischarging from mental health services against the Trust’s own policy on patients who do not engage or fail to attend appointmentsdischarging from the Community Treatment Team and not communicating this decisionnot following relevant national NICE guidancefailing to fully consider adult safeguarding policy failing to assess the need for aftercare under section 117 of the Mental Health Act 1983

7. Mental Health Code of Practicehttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/435512/MHA_Code_of_Practice.PDF“The one thing that makes a difference is knowing that your voice is being heard and that we feel listened to by others”Expert Ref Group service user

8. Not being listened to at Southern Health NHS – Carolan reportThe strongest theme that emerged from the interviews with families, mentioned by almost all the families : Difficulty getting mental health workers to listen to themNot being able to access the level of support that was needed. A number of families suggested that the consequence of not being able to get appropriate, timely support was the death of their loved ones.Carolan Report Oct 2016 - Southern Health NHS file:///C:/Users/user1/Downloads/A%20review%20of%20family%20involvement%20in%20investigations%20conducted%20following%20a%20death%20at%20SHFT%20(2).pdf

9. GMC Complaint – 5 year processGMC complaint One Doctor stuck off the medical register.GMC eventually admitted that the expert report that they used to initially determine that no action should be taken against a second Doctor was deficient and flawed. The complaint against the second Doctor resulted in admitted maladministration by the GMC and resulted in a Judicial Review and no action taken against the second Doctor.

10. Working with patients and families in investigationsAs soon as possible after a death – speak to the family and have someone visit them that is trained in this important task. Ask if they have any concerns about the death. Explain what will happenAsk them how you can support them and do it.BE HONEST WITH THEM AND TELL THE TRUTH

11. What else happened at Southern Health - Inquest Ellie BrabantInquest into death of Ellie Brabant 05/11 to 12/11/18Self-inflicted death of Ellie Brabant - Coroner finding that the lack of a clear care plan, and the decision to discharge Ellie from Section 3 of the Mental Health Act more than minimally contributed to her death. Ellie, 28, was found hanging whilst an inpatient at Antelope House, a mental health unit in Southampton on 2 November 2017.She had spent most of her adult life detained under Section 3 of the Mental Health Act.Alice Stevens, Solicitor at Broudie Jackson Canter Solicitors, said: “This is a deeply disturbing case. Ellie was a vulnerable patient with complex needs who was not afforded proper care and attention by those responsible for her care. The inquest was a frustrating process for Ellie’s family with Trust staff disagreeing with independent experts who were highly critical of the care afforded to Ellie.  

12. Inquest - Ellie BrabantIn the months leading up to her death, Ellie was moved five times and spent time in a Psychiatric Intensive Care Unit due to escalating self-harm. Within nine days of residing in Antelope House, Ellie was made a voluntary inpatient. She subsequently utilised regular leave from hospital during which she reported being raped and taking drugs.A Prevention of Future Death report has been written by the coroner -Staff training around the importance of, and implementation, of observations of patients;Safeguarding of patients at risk of crimes and reporting these to police. The coroner noted that vulnerable patients like Ellie need to be safeguarded and further training on informal patients are needed;The coroner has also written to Southern Health Trust in relation to their conduct, including concerns about the preservation of evidence following serious incidents and late disclosure of evidence at the inquest.

13. Family and Inquest organisation viewEllie’s family said: “We are devastated by Ellie’s death and the failures in her care at Antelope House. We were not given the opportunity to feed into Ellie’s care and were instead left to watch her rapid decline. The Ellie who took her own life was not the Ellie we knew. Although we accept procedural changes have been made following Ellie’s death, we do not believe these changes address the fundamental deficiency in Ellie’s care. We do not feel confident that should another patient like Ellie be under Southern Health’s care, anything would be done differently. Inquest Organisation said “Once again, the conduct of Southern Health Trust suggests a greater concern about reputational management, rather than the opportunity to identify where they have failed to keep people safe.”https://www.inquest.org.uk/inquest-concludes-ellie-brabant

14. Southern Health NowFined over £2 million pounds for HSE offences where patients have died.Broken Trust TV programme - Whole Board changed - Execs and Non Execs.Three relatives have presented to the main Board about a compelling need to change and asked for 17 recommendations to be instigated in 2018.One of the most important will be the appointment of an IME. NHSI – Appointed Nigel Pascoe QC - review the investigations of 5 deaths of patients.Pascoe report – Published Feb 2020 https://www.england.nhs.uk/south-east/wp-content/uploads/sites/45/2020/02/060220-Report-pdf2.pdfPascoe 2 - Public Investigation Hearings – taken place April 2021 – families declined to be involved. Report published Sept 2021.https://www.england.nhs.uk/south-east/publications/ind-invest-reports/southern-health/

15. Was his treatment by the NHS what he neededI believe that my son had a brain injury at birthHe never had any test, brain scans or investigation.Given Ritalin at 9 years of age for ADHD.

16. Charles Dickens – Tale of Two NHS Cities It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to heaven, we were all going direct the other way

17. NHS Behcets Clinic London1995 – 2012 - Doctor’s treating me - GP who knew nothing about Behcet’s disease and a Rheumatologist in London who was a specialist in Behcets. 2012 – until nowProfessor Farida Fortune – Clinical Lead, Consultant in Oral Medicine and ImmunologyTBC– Clinical Nurse Specialist / Centre ManagerNardos Wakjira – Lead Dental NurseProfessor Ali Jawad – Consultant RheumatologistProfessor Miles Stanford – Consultant OphthalmologistDr Matthew Buckland – Consultant ImmunologistDr Desmond Kidd – Consultant NeurologistDr Steve Higgins - PsychologistDr Amanda Willis - StR in Oral MedicineDr Noha Seoudi - StR in Oral MicrobiologyDr Bindi Gokhani - Specialty Doctor / DentistSheila Bower – Business Administration ManagerBridie Sweeney - AdministratorMarie Simpson - SecretaryJean Christians – Support Coordinator

18. NHS Complaints FrameworkNHS New framework – Patient Safety Partners. Previous NHS frameworks for complaints has not worked.PHSO – new framework. 12/24 months after an event - Not in real time. Investigates very few complaints compared to those reported to the organisation. Should be Real Time Investigations and Obtaining a written witness narrative from carers/relatives/witnesses – not a report of your interpretation of what they said.Begin to measure all outcomes – costs v benefit and build a feedback system that asks patients and relatives to comment on the treatment they have received.

19. Research Project – Open University- Witness to harm, holding to account: Improving patient , family and colleague witnesses’ experiences of Fitness to Practise proceedingsImproving the experience of witnesses in health and care professional practice proceedingsWorld’s first study of this kindWorking with 13 UK regulators of health and social care.30 month projecthttps://www.open.ac.uk/research/news/improving-experience-witnesses-health-and-care-professional-practice-proceedings