Tweet
Afternoon All,
A few years ago, my stepson tragically took his life. In the week before his death, both his mother and I called the county mental health team, citing our concerns that he was at imminent risk of taking his own life. He was classified as requiring 'urgent 72-hour triage'.
It's worth noting, that there are are four levels of 'urgent' triage - and 72 hours is deemed the least urgent, being category D.
A Category of triage requires an immediate response (Emergency)
B Category requires 4 hour response (Very high risk of imminent self-harm to self or others)
C category requires 24 hour response (High risk of harm to self or others)
D Category requires a 72 hour response (Moderate risk of harm)
On the afternoon the day before his death, I was aware that the situation was critical, so I phoned the county mental health team (his Mum had already phoned them 3 or 4 times) - unfortunately, I spoke to a Trainee, who didn't seem familiar with procedures - I was told that 'they couldn't do anything'. Ultimately, I was told that 'if there are concerns, contact the emergency services'.
Given our concerns, I can't understand why he wasn't classified as Category A or B. Giving me the advice of 'contact the emergency services' doesn't seem in line with the classification of Category D - 'moderate risk of harm'.
The above information is just to present a picture of the situation - I'll now get to the point.
At the inquest, the Coroner observed that my recollection of the content of the telephone call to the County Mental Health team was at odds with their version of events. The Mental Health Team admitted that they advised me to call the emergency services, but on every other point, they disagreed with what I had to say.
The Coroner mentioned that there was a significant difference in my version of events and those of the County Mental Health team. The leader of the County Mental health team was asked by the Coroner, if telephone calls are recorded and he was told that they were not. He said that he would make the recommendation, that in future, all calls be recorded and held for 30 days and retained indefinitely in similar circumstances.
About 10 days later, we received a FYI email from the Coroner, with a letter attached that he had been sent by the 'parent' authority of the Mental Health Team. It said that he had been 'mistakenly informed' and that telephone calls were recorded and held for 30 days and retained if necessary.
In a nutshell, the Head of the County Mental Health team told the Coroner that telephone calls were not recorded - they must have known this was untrue, but that's what he was told. The day after the death, we notified the County Mental Health Team - at that point, they 'should' have retained our telephone calls indefinitely, but they didn't - why not ?. The fact that the telephone calls were 'lost', certainly didn't help me to put our points across at the inquest.
If we were to submit a complaint, I presume that we'd have to prove breach of duty of care and causation; in any circumstances, this would be very difficult; however, it becomes virtually impossible, given that they've not retained any of our telephone calls - there's no evidence as they've deleted it - which seems very convenient.
It seems incredible to me, the someone can 'mislead' the Coroner with impunity; is there no remedy for something like this ?
A few years ago, my stepson tragically took his life. In the week before his death, both his mother and I called the county mental health team, citing our concerns that he was at imminent risk of taking his own life. He was classified as requiring 'urgent 72-hour triage'.
It's worth noting, that there are are four levels of 'urgent' triage - and 72 hours is deemed the least urgent, being category D.
A Category of triage requires an immediate response (Emergency)
B Category requires 4 hour response (Very high risk of imminent self-harm to self or others)
C category requires 24 hour response (High risk of harm to self or others)
D Category requires a 72 hour response (Moderate risk of harm)
On the afternoon the day before his death, I was aware that the situation was critical, so I phoned the county mental health team (his Mum had already phoned them 3 or 4 times) - unfortunately, I spoke to a Trainee, who didn't seem familiar with procedures - I was told that 'they couldn't do anything'. Ultimately, I was told that 'if there are concerns, contact the emergency services'.
Given our concerns, I can't understand why he wasn't classified as Category A or B. Giving me the advice of 'contact the emergency services' doesn't seem in line with the classification of Category D - 'moderate risk of harm'.
The above information is just to present a picture of the situation - I'll now get to the point.
At the inquest, the Coroner observed that my recollection of the content of the telephone call to the County Mental Health team was at odds with their version of events. The Mental Health Team admitted that they advised me to call the emergency services, but on every other point, they disagreed with what I had to say.
The Coroner mentioned that there was a significant difference in my version of events and those of the County Mental Health team. The leader of the County Mental health team was asked by the Coroner, if telephone calls are recorded and he was told that they were not. He said that he would make the recommendation, that in future, all calls be recorded and held for 30 days and retained indefinitely in similar circumstances.
About 10 days later, we received a FYI email from the Coroner, with a letter attached that he had been sent by the 'parent' authority of the Mental Health Team. It said that he had been 'mistakenly informed' and that telephone calls were recorded and held for 30 days and retained if necessary.
In a nutshell, the Head of the County Mental Health team told the Coroner that telephone calls were not recorded - they must have known this was untrue, but that's what he was told. The day after the death, we notified the County Mental Health Team - at that point, they 'should' have retained our telephone calls indefinitely, but they didn't - why not ?. The fact that the telephone calls were 'lost', certainly didn't help me to put our points across at the inquest.
If we were to submit a complaint, I presume that we'd have to prove breach of duty of care and causation; in any circumstances, this would be very difficult; however, it becomes virtually impossible, given that they've not retained any of our telephone calls - there's no evidence as they've deleted it - which seems very convenient.
It seems incredible to me, the someone can 'mislead' the Coroner with impunity; is there no remedy for something like this ?