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“Where is this going to end??”

This was the question that I asked in desperation on 21st May 2015  to one of the agencies involved with Jake’s care. Well, It ended with Jake’s suicide on the morning of Sunday 23rd August 2015. The previous day, Jake attended an important appointment  (20th May 2015)  with the expectation of being issued with a ‘safe’ prescription plan for Diazepam. Both Jake and I were feeling hopeful about this appointment.  Finally, it felt like things were progressing in the right direction.  To cut to the chase the Clinical Psychiatrist did not prescribe. Jake was very angry and I felt completely floored. The next morning I sent the email. My concerns were that Jake, now had no hope, no prescription, no MH assessment, no care plan and was being passed from pillar to post. At the end of this email I asked the question “Where is this going to end?”

The 20th May 2015 haunted me for some time after Jake’s death, because the outcome of that appointment, was I believe the impetus for Jake’s thought processes to move even closer to taking his own life. Jake’s words to me were “Mum, no one can help me now”.   It was like he had switched on that green light, the one that gives permission to do it, the one that justifies someone’s suicidal thoughts and makes it even harder for them to battle with these thoughts each day. I think we both felt totally helpless. It was very, very hard to cope with. In the days and weeks after Jake died I found the email with the question and it made me feel sick to the core.

I would like to make it very clear that as much as I absolutely believe that the negative outcome of that appointment on 20th May 2015 was the beginning of the end for Jake, I do not point any finger of blame.  It is an observation of how the events of that appointment affected Jake, not a criticism.  That said, it has taken some time for me to reach this point of understanding. In fact it took me almost 2 years.

I held a very negative view of the Clinical Psychiatrist who I will now refer to as Dr Y.  I was working and not able to attend the appointment on 20th May 2015 with Jake and was not aware at this time that his substance misuse case worker (from a different agency) should have been notified and should have attend with Jake. Following a Serious Incident Report and the Inquest into Jake’s death there were a number of issues raised with regard to how this organisation and Dr Y had cared for Jake.  These issues formed part of the Regulation 28 (recommendations to prevent further deaths) issued by the Coroner.  I was offered the opportunity to meet with Dr Y on a number of occasions, but I just couldn’t face her.  I met with many others and followed other things up, but I just could not bring myself to meet with her.

It was just short of the 2nd anniversary of Jake’s death and I decided that as my feelings towards Dr Y who, at this point in my mind was a faceless demon, were not going away, I decided to, request and arrange a meeting with her.  The meeting was arranged.   Myself,  Dr Y and The Manager of this organisation (who I knew well) would be in attendance.  I had such high expectations from this meeting (I could not even really tell you what they were) but I think the key thing was that I wanted to like her (Jake did not have a good word to say about her), I wanted to understand.  When I was preparing  to attend this meeting I wanted so much to find answers, but had a sense of dread that I could come away from that meeting feeling totally let down and deflated.  I have to say that Dr Y and the Manager were very generous with their time.  The plan was that they would set aside 2 hours on a Tuesday afternoon and if we needed to continue the conversation then they would be available same time, same place the week after and onwards, until I felt closure.  We did only need the one meeting.

At the start of the meeting, I began to cry, so needed a little time to compose myself and take in the importance of this meeting.  I could not decide if Dr Y was coming across as guarded or aloof. After some time I started to get that sinking feeling that I wasn’t really getting anything from this meaning and felt frustrated.  I decided to ask a direct question “If Jake walked in here today, what would be different”?  Well, at this point Dr Y became quite animated, more open and less guarded.  She answered my question by referring to 2 recent cases similar to Jake’s and was able (without breaking confidentiality) to absolutely assure me of the changes that have come about since Jake’s Inquest.  The Manager who I knew well and who had attended Jake’s Inquest said to me that,  hand on heart he could say that all of the barriers and obstacles that were there previously have all gone and the process for prescribing is far more efficient.

It took about 3 days to process my thoughts of how I felt about the meeting.  My thoughts settled at an understanding that the answers are the changes.  What happened to Jake will never be good enough and I can’t change that, but things have changed for others and that is what I need to focus on.  This meeting was a turning point for me, I was able to feel a weight lift from  my shoulders and I no longer had to worry about the month of May.

Did I like Dr Y after the meeting?  Not sure, but she put me straight on a few myths that I had held in my mind and I can say that I have respect for her.