Inquiry into Suicide Prevention

HISTORY OF XXXXXXXX’S ILLNESS

My name is XXXXXXXXXXX.  I am 42 years of age and live with my husband XXXXXX and three children.  On the 2^nd December 2016 my brother in law, XXXXXXX, took his own life due to depression at the age of XX.   

XXXXXX was an extremely intelligent man with everything to live for.  He went through University and gained a Bachelor of Arts and Masters Degree.  XXXXXX went on to work as Sports Manager at XXXXXXX University.  Unfortunately, XXXXXX went through a very acrimonious divorce.  During his divorce his ex-wife stopped all access to their two children and it was a very difficult time for all the family.  XXXXXX saw a solicitor to enable him to have access to the children and after a very lengthy process he was granted weekly access, unfortunately this cost XXXXXX over £36.000 and he was forced to take voluntary redundancy in order to pay the solicitor fees. 

XXXXXX spent most of his time after his redundancy looking for a permanent job.  He joined an agency where he was given hours as a supply teacher in the comprehensive schools in XXXXXXXX and XXXXXXX.  XXXXXX applied for many posts but was deemed ‘over-qualified’ and he found this very difficult.  As time passed, even though XXXXXX was seeing the children he became very distant, obsessed with trying to find work. 

In January 2016 XXXXXX started coming to my home almost every day.  He informed me that he was feeling very low in mood and did not see the point in anything anymore.  We talked for hours about how we could make things better but he struggled to see anything in a positive way.  As the weeks passed XXXXXX became more and more depressed to a point where he was coming to see me and spending the entire time crying, rocking back and forth and telling me that he felt extremely depressed.  At this point I advised XXXXXX that he needed to see his doctor and I offered to go along with him.  He informed me that he had already been to see his GP in the past and he had been on anti-depressants for a while but they were not working as well. 

I attended the GP surgery with XXXXXX and the GP arranged for XXXXXX to see a Community Psychiatric Nurse in the GP Surgery for assessment.  I went along with XXXXXX and we sat in the office with a female nurse for almost 2 hours.  XXXXXX explained to her that he felt very depressed and that nothing made him happy.  He explained that he had gone through a very bad divorce and had lost his children.  She asked him if he felt like he wanted to hurt himself and he said he had thought about it but he had no intentions of doing anything about it.  XXXXXX explained to me on a few occasions that he was not ‘brave enough’ to take his own life.  The nurse explained to XXXXXX that counselling would help and that they would change his prescription.  Unfortunately there was a very long waiting list to see a counsellor and XXXXXX would have to wait. 

During the next few months XXXXXX went from crying constantly to talking about the same things over and over again.  He would come and see me almost every day and if I was not at home he would ring me on my mobile.  He would panic if he could not talk to me and was scared that I would die and he would have nobody to talk to (even though his family tried to be very supportive).  XXXXXX constantly went over his divorce and the issues that went along with it.   He would repeat the same things over and over and this would go on for 3-4 hours at a time.  XXXXXX returned to his GP surgery and his GP changed his prescriptions on a few occasions but nothing seemed to be helping. 

By June 2016 XXXXXX had started to talk about taking his own life.   At this point I knew that he needed to be seen urgently and I asked him to arrange another appointment with his GP.  XXXXXX was given an appointment to be seen at XXXXXX by the Mental Health Team.  I went along with XXXXXX to this appointment and XXXXXX was seen by two professionals, a male and a female.  XXXXXX told them how he felt and that he had thought of taking his own life.  He told them that he thought about the same things over and over and that he could not stop thinking.  He explained that he couldn’t concentrate when he was at work as a supply teacher and that nothing made sense to him anymore.  The male professional was very calm and supportive with XXXXXX but the female was finding XXXXXX very frustrating, unfortunately XXXXXX picked up on this and asked her if she was ‘finding him frustrating’.  She replied ‘yes XXXXXX, I am, because you are not willing to accept any help and we are trying to help you’.  I did not find this very professional but I assumed that they were the experts on this and knew what they were doing.  They told XXXXXX that depression did not last and in 6 months he would feel much better.  XXXXXX told them that ‘he would be the one to prove them wrong’.  He was adamant that he would never feel any better.  When asked if he knew how he would take his own life he informed them that he had not thought about it and even though he had considered it he currently had no suicidal intentions. This was all they needed to transfer XXXXXX back to primary care!!!!

After months of XXXXXX constantly wanting to talk to me, suddenly in August he stopped.  He informed me that he was okay and did not need to speak to me anymore and put the phone down on me.  I was very wary of this and it deeply concerned me.  I rang XXXXXX again and asked him why he did not feel he wanted to talk to me and he told me he had made his decision.  He again put the phone down on me and again I called him back.  After pushing him to tell me what he meant he finally admitted to me that he had bought a rope and in the morning, after dropping his child off at school, he was going out in his car with the intentions of taking his own life.  I informed his parents immediately of what he had said and first thing in the morning my husband drove to the house and took XXXXXX’s car keys from him.  XXXXXX’s dad took the little one to school and I drove down after dropping off my children at school. 

When I reached the house XXXXXX was in a terrible state.  It looked like he hadn’t slept in weeks and he was very annoyed that we had stopped him going out.  I begged him to let me take him to the doctors but he was adamant that he wanted to ‘end his life’.  I rang the doctor’s surgery, who were amazing, and asked me to bring XXXXXX immediately to the surgery.  It took some time to convince him to come with me but he eventually did and was seen by the GP.  The GP rang XXXXXXX expressing her concern that XXXXXX would hurt himself and we were asked to take him straight there. 

When we reached XXXXXXX we were invited into a room with a few people.  They assessed XXXXXX and were extremely concerned that he had not slept in weeks.  They asked him if he would admit himself but he was not happy with this and was told that if he did not admit himself then they would have no choice but to section him.  XXXXXX eventually admitted himself to XXXXXX.  We were informed that XXXXXX would be given tablets to help him sleep and monitored regularly to ensure his safety.  In the week he would be seen by doctors who would arrange treatment for him. 

During the week that XXXXXX was in XXXXXX he spent most of his time either outside in the courtyard smoking, walking the corridor or lying in his bed.  He did sleep, looked physically better and seemed calmer but he was still extremely low in mood and could see no way forward.  XXXXXX was sectioned on the second day of admission as he was asking to leave the hospital.  We were initially informed that XXXXXX, whilst an in-patient, would receive treatment such as counselling, etc.  However, we are not aware of XXXXXX having any treatment in XXXXXX other than medication for his sleep and them trying stronger medication for his mood.  XXXXXX told me on many occasions that he was ‘left alone’ most of the day and he was extremely unhappy in there. 

I visited XXXXXX on the third day of his admission and he was not in the hospital.  I was told by the staff that they allowed XXXXXX to go out for a walk but he had to be back at a certain time.  Although XXXXXX did return, I was quite surprised that after being sectioned he was suddenly being allowed out. 

By the end of the week XXXXXX seemed calmer (although he was still telling me that he could see no way forward and nothing made sense).  He was reviewed by the Consultant Psychiatrist and I went along to the meeting, there were quite a few other staff there too.  XXXXXX explained to the Psychiatrist that he was feeling a little better, still low in mood but he did not want to hurt himself anymore.  I agreed that he was definitely better than when he went in and XXXXXX was discharged from XXXXXXX.  I asked the Psychiatrist if XXXXXX would receive further follow-up and was told that a CPN would be put in place for him. 

A few weeks after XXXXXX’s discharge, he still had not received any counselling and had no CPN.  I rang the Consultant Psychiatrist secretary and it appeared that one had not been put in place for him.  I was assured that this would be arranged as soon as possible. 

The next few months XXXXXX was still very low in mood but unfortunately, due to his change in medication he had developed tinnitus as a side-effect.  This made him feel worse and not only did he have the depression to deal with but also the constant ringing in his ears.  XXXXXX had not seen his children for almost 6 weeks but refused to see them as ‘it would be easier for them when he was gone’.  We tried everything to keep XXXXXX busy, tried to get him involved in everything but he just was not interested. 

At the end of November 2016 XXXXXX took a huge overdose of sleeping tablets at his parents’ home.  He was found by my husband who is a XXXXXX and taken to hospital by Ambulance.  Thankfully, he was okay and spent the night in hospital.  He was reviewed by the Hospital Psychiatrist and XXXXXX told him that he was fine and would not attempt suicide again. He was informed that they would refer him to see a specialist regarding his tinnitus and he was discharged. 

XXXXXX’s dad collected him from the hospital and begged them to section him but they said they could not as XXXXXX had informed them that he had made a mistake by taking the tablets.  XXXXXX was seen daily by a team from XXXXXXX who visited him at home to assess him.  XXXXXX told them he was fine but when they left he was telling his parents that he was going to end his life.  His parents begged the team to do something, telling them what XXXXXX was saying to them as soon as they were gone but they said they could not do anything. 

The following week XXXXXX told the team that he did not need to see them every day and could they leave it a few days, they agreed.  XXXXXX took his own life that week. 

IMPORTANT POINTS

There are many things that are good with the Mental Health Service in Wales, however, there are also things that need to change. 

1. XXXXXX needed to see a counsellor urgently.  There is a very long waiting list to see a counsellor and XXXXXX died without ever seeing one.  On speaking to a friend of mine the other day I discovered that she has been waiting to see a counsellor for 9 months. 

Surely, in XXXXXX’s severe case, a counsellor should have been a priority.  You could clearly see that XXXXXX was in a state of despair.  He informed the medical staff that he had thought about suicide but had no thoughts on how, when and where.  I feel this is irrelevant as he has disclosed the fact that he has thought about it. 

2. When XXXXXX saw the staff at XXXXXXX for the first time, he was immediately transferred back to primary care because again he did not know if, how and when he was going to hurt himself.  Again, surely the fact that he had thought about it was enough to start the ball rolling with regards to further treatment, counselling, etc.  XXXXXX remained on the waiting list for counselling and this appointment did not speed this up.  Is it normal for a member of staff to inform a patient that they were finding him very frustrating?

3. It finally got to a point where XXXXXX was desperate and actually informing us that he was going to take his own life.  I must say that at this point the GP Surgery were amazing.  They asked us to take XXXXXX there immediately and the Doctor rang XXXXXX to say she was extremely concerned about XXXXXX.  However, XXXXXX now had physical signs of an illness, why was he suddenly being taken seriously when before he was desperately ill (mentally) but did not look ill.

4. XXXXXX was not counselled in XXXXXX during his admission.  The only treatment he received was observation, medication change and sleeping tablets.  He was even allowed to leave the hospital during his admission, alone.  Why did he not receive the counselling he so desperately needed. 

5. It was promised that he would receive regular follow-up after his discharge but nothing was done.  In fact, the only reason anything was put in place was because I chased this up myself. 

6. When XXXXXX was admitted to hospital after his overdose he was discharged the following day.  XXXXXX had already been sectioned and had now taken a huge overdose yet this wasn’t enough to have him sectioned for treatment.  He was informing the staff that he was fine but telling his parents that when he went home he was going to ‘do it properly’.  His parents informed them of this but XXXXXX was still discharged.  A team were put in place though to visit XXXXXX at home and we appreciate that they did put this in place.  

7. The team that visited XXXXXX were fabulous but why did they not take on board what XXXXXX’s parents were telling them about him threatening to take his own life.   XXXXXX was telling the team that he was okay but he wasn’t and we feel that the family’s views need to be taken into account. 

8. Even though the family were informing the team about what XXXXXX was saying, the team still did what XXXXXX asked and did not come back to the house.  XXXXXX took his own life a few days later. 

CONCLUSION

I fully understand that mental health problems are extremely difficult to manage but I feel that things need to change.  Counselling needs to be made available immediately, especially in cases where the person is threatening to take their own life. 

Whilst in hospital with mental health issues, the patient needs to receive more care to deal with the issues they have and not be left to constantly mull over these issues because they are being left alone.   They need to discuss their worries and how they feel and counselling should be readily available.  Should they really be allowed out whilst being sectioned for their own safety?

Families matter – listen to what the families are saying as they spend every hour with this person, listening to what they are saying.  The families know when their loved one is being honest or trying to deceive someone.  More time should be spent talking to the families of the patient to get their opinion on how the person is and how their mood has been. 

Classes could be run for families of patients suffering with mental illnesses to make them more aware of what is happening to their loved one and what to look out for.  I spent many hours researching XXXXXX’s condition on the internet but this information needs to be readily available for people who do not have this option. 

XXXXXX was suffering and his depression was getting worse due to the tinnitus, an unfortunate side-effect of his medication.  Surely, in this case, an immediate referral and appointment should be made as this would be one less thing for that person to worry about. 

I know that money is tight within the NHS but I do feel that more should be put into the Mental Health Departments and maybe more time spent trying to understand this dreadful illness.