Mental Health Failings, a friend lost

TRIGGER WARNING: suicide, self harm
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A friend of mine died last night.
She committed suicide while in the "care" of a mental health unit.
She had been ill for a long time and had a long history of self harm and suicide attempts. During the past couple of years she probably spent more time as an inpatient than out.
Though I'm grieving, another overriding emotion is anger. This should never have been allowed to happen.

I had already been very angry at the care she received at a previous mental health unit.
When I visited she did not seem to be properly monitored.  Staff turnover was high, with many agency workers who did not always seem to know her needs.
Her treatment and medication reviewing was poor and sometimes postponed for over a week due to "timetabling".
She was once physically assaulted by another patient. Over another period of time she was regularly followed around by another male patient who developed a fixation on her. Staff did nothing about it.
While there she regularly "succeeded" in harming herself, badly enough to require serious ongoing hospital treatment.
She also "escaped" from the secure unit several times and then attempted suicide.

What kind of "care" is that??! If my friend wasn't safe in the mental health unit, then where could she be? What kind of "professionals" allow that to happen?

In later months, after my friend had left the area, the unit she had stayed in dramatically failed a surprise inspection and was threatened with closure as "mental health patients were put at risk". Among other things it was found that:

Drugs were “not always handled appropriately” while staff “did not always ensure that medicines were safely administered”.
Patients were “at risk of not receiving appropriate treatment to meet their needs” as vital care plans and risk assessments failed to ensure their safety and welfare.

In a way I was relieved. My suspicions were confirmed. But this surely meant that this was just one bad apple and that any future care she received elsewhere would be much better?

Now, in yet another mental health unit, my friend has once again been let down.
She wasn't properly monitored.
She wasn't safe.
But this time it won't matter what excuses are made.
It won't matter what "lessons are learned".
For my friend it is too late.





EDIT: April 2016

It is 2 years on. Following the death of Connor Sparrowhawk due to neglect while in the care of NHS trust Southern Health and the tireless efforts of his mother Dr Sara Ryan to uncover the truth behind it, terrible facts are now coming out.

An independent review was undertaken at the end of 2015. The Mazaars report found that the trust failed to report and investigate the deaths of hundreds of people with learning difficulties and mental health illness while in its care.

Following this, a CQC inspection was ordered, which Southern Health has spectacularly failed.

Among other things serious concerns were raised about the safety of mental health patients. 

For example, CQC had identified concerns relating to ligature risks in acute inpatient mental health and learning disabilities services in January 2014, October 2014 and August 2015. During the January 2016 CQC found that the Trust had still failed to make sufficient changes to address these risks with many potential ligature anchor points identified at one location.

The trust's chairman has resigned and the board and chief executive are now being called upon to stand down.

I'm not entirely sure how I feel about all this.  I feel I owe a debt of gratitude to Dr Sara Ryan for taking on the trust. I have followed her fight and it has truly been a David vs. Goliath battle. I know she was doing it for her son, but at the end of the day, she has also found justice for people like my friend too. Judging by the reports, perhaps hundreds of people.
More importantly, perhaps this will save future lives, and THAT is what is important.