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The Inquest & The Missing Letter

The Inquest into Jake’s death was scheduled for 3rd December 2015. The support and guidance I received from the Coroners Office was professional, informative and sensitive. Despite this, nothing can really prepare you for an Inquest into the untimely death of your only child. You want that day to come, but at the same time you want to fast forward and for it to all be over.
I was interviewed by a Police Coroners Officer in the first few weeks after |Jake’s death and was disappointed when told that the interview would be conducted over the phone. I was expecting face to face, so this just felt like the assumption had been made, that Jake would be just another young male suicide. One of the 6,188 suicides of 2015, a statistic. However, I have to say that this Police Coroners Officer was very thorough, our phone call lasted over an hour and a half and when I received the written statement for me to check and sign, I was impressed and felt reassured by the detail.
I was feeling incredibly anxious and nervous during the build up to the Inquest. I knew that Journalists, could attend and report on the Inquest. I was told that it just depends on what else is of interest to them on the day. I had no idea if Jake’s suicide note would be read out. I was asked by the Coroner’s Office if I wanted to know what it said, I was unsure. She hinted that it was along the lines of the phrases that Jake would often use like “There is a future that is calling, but I don’t see it coming”. How very, very sad.
I received a letter notifying me of who was to be called to the Inquest as a witness – myself, my brother, Detective Inspector, Toxicologist, Trafford Aim. Phoenix Futures, GMW Mental Health Foundation Trust. We were all expected to give evidence. The Pathologist, GP, CMHT & RAID were only required to submit statements to the Coroner.
So, the day came and I felt sick to the core. I arrived at the Coroner’s Court and waited in reception until all witnesses had arrived and signed in. I spoke to a member of staff from Trafford Aim and she started crying, which set me off. Then the Detective Inspector introduced himself, the room was filling up quite quickly now and then a lady came over and introduced herself as, the Police Coroners Officer who had interviewed and supported me. I had never actually met her and I thought that this was such a lovely touch.
The last witness to arrive was the person who carried out the Serious Incident Report. If you have been following my blogs then you will be aware that after the SIR was written I raised an important question about a ‘missing letter’ just one week before the Inquest. She came over to me and appeared to want to share some information with me, she looked quite anxious. There wasn’t time to talk, as we were all ushered upstairs to the court room.
It took me a while to fully take in the room. There was a long table with microphones and name cards for the 7 of us who had been called to give evidence. There were a number of seats behind our table for anyone else who was attending. The room was full and I kept scanning it to work out who was who. Every witness other than the DI and Toxicologist had brought at least one other person with them i.e. their manager, area manager, other representatives. I managed to work out who everyone was or at least who they were with, so I felt relieved that there were no journalists.

We all had to stand whilst the Coroner Joanne Kearsley entered the room. When I need to stay focused, I can do it, and on this day, I was determined not to be tearful, but instead keep my wits about me and listen to every word. |I felt very strongly that I had to represent Jake and expose the shortfalls that he had experienced. I had to make sure that no stone was left unturned.
I was the first witness to take the stand and I was nervous. The Coroner took me through the statement that I had submitted, starting with what Jake was like as a child etc. and then she jumped to the final few months of his life and then to the final day. Then she stopped and said ‘do you have any questions?’. I looked around the room in disbelief thinking you have missed out the most important elements of my statement. I looked at her puzzled and said ‘you haven’t asked me anything about Trafford Aim’. She looked at me very sternly and then around the room which was silent and said in what seemed a patronising tone ‘you will get the opportunity later to ask questions’. Well, that was me told. It took me about an hour to realise just how the role of a Coroner works. I worked out what she was doing and was very impressed.
The other witnesses were called to the stand. The DI went through the facts regarding the day and the scene of Jake’s death. I learned of the planning and the sophistication that went into how Jake hung himself using ratchet straps. The Pathologists summarised on Jake’s post mortem report that Jake had died very quickly. The evidence for this was the fact that there was very little bruising to the neck which meant that his heart stopped very quickly. I guess that means he didn’t struggle.
The Toxicologist was up next. She faced the Coroner when being asked a question, but she then turned around and directly faced me when giving her answers. This way of communicating in such a formal environment is something that I will never forget. She also explained the toxicology results in a way that I could understand.
When Jake’s case worker from Phoenix Futures took the stand the Coroner actually smiled at her (I think this was the only time that she did smile) and went on to outline the fantastic relationship that she had built with Jake as his case worker and the work that Phoenix Futures had done with Jake.
Next to take the stand was a representative from Trafford Aim. This witness did know Jake, but only for a short time as there had been staffing issues/changes. I hold an awful lot of negativity towards Trafford. The Coroner did expose everything that I thought of them and more. However, I have to say that I felt for this witness, as in my opinion she was ‘pushed under a bus’ by Trafford Aim. She was not prepared or supported, she was pulled apart by the Coroner and although Trafford Aim deserved this, she didn’t.
So now we come to the Head of GMW Mental Health Foundation Trust who had carried out the Serious Incident Review. This person is experienced at giving evidence at Inquests, but \I must say she seemed nervous. To cut to the chase she was given a very hard time by the Coroner and things were about to get worse. THE MISSING LETTER.
So, rewind to the SIR report and the fact that only a week before the Inquest |I pointed out that a very important piece of correspondence was nowhere to be seen in the report. There had only been about 4 working days for this person to look into this and only the day before the Inquest had she found out that a very important letter had indeed been faxed from a GP to Trafford Aim. It had been faxed to the correct number and had been logged as sent successfully. However, Trafford Aim had no record of this fax/letter. This was what she wanted to talk to me about when she arrived at the Coroners Court but we were ushered upstairs.
This witness had to inform the Coroner during her time on the witness stand that it would appear that there is a ‘missing letter’ that does not feature in the SIR report.
Well, if the Coroner could have done a vertical take off then I think she would have. Her face became even more serious than the serious expression she had already shown throughout this Inquest. You could have heard a pin drop in that room. I was on the edge of my seat. The Coroner asked for more detail and she allowed me to speak and briefly explain even though I was not in the witness stand (only those on the stand are allowed to speak).
The Coroner looked this witness in the eye and said “are you telling me that a significant letter was sent in June by a GP to Trafford Aim that should have resulted in Jake receiving a safe prescription for benzodiazepines and there appears to be no record of it?”
“Yes” was the reply.
The Coroner ordered an immediate investigation into the missing letter with a short time frame to feedback and then issued a Regulation 28 which is a report to prevent future deaths. She bowed and left the room.
I am proud of Jake for fighting so hard to live whilst battling with suicidal thoughts. If he had not have shared all his thoughts, his feelings, his behaviour and his appointments with me then this Inquest would have been an open and shut case and the Coroner would not have known the half of it and changes would not have come about since Jake’s death
The Court Clerk came over to me at the end and said “you did really well, well done”
I guess I managed my goal which was to stay focused and fight Jake’s corner.
This experience was quite exhilarating which may not seem like the most appropriate word, but I was running on adrenaline for a couple of weeks after this Inquest from the sheer relief at how well it actually went.
Proud.
Much Love.x

The Serious Incident Review & The Missing Letter

Jake’s untimely death by hanging triggered a ‘Serious Incident Review’ carried out by the GMW Mental Health Trust. I was invited to attend a meeting at the trust on 07/10/2015 with Ms. F, Service Manager CMHT and EIT.  The meeting lasted over an hour and a half and I felt confident that I had been listened to and that my key questions would be answered in the review.

The morning after the meeting I received an email from Ms F to say that she had found our meeting ‘tragic, yet heartwarming at the same time’  I often remember these words.

Whilst waiting for the Review to be completed I was also having to deal with the Coroners Office in preparation for Jake’s Inquest which was scheduled for December 3rd 2015.  Looking back, I don’t know how I managed to stay so focused, I guess I may well have still been in shock.

There was an extension given to the deadline for the SIR as more time was needed to carry out investigations. Finally the report was complete and I was invited back to the GMW Mental Health Trust to meet again with Ms F.  I remember making the journey to this meeting hoping for the best, but knowing that I could come away feeling totally let down.

The report was right there on the table between us and I felt sick with stress.  Ms F explained that she would talk me through the report and summarise the key findings. It was difficult for me to take in each page and all of the words.  When I was more settled, It started to make more sense. My overwhelming feeling was that this report lacked a backbone.  The language was dumb’d  down in places and comments like

“It is unusual for someone of Jake’s age to have a Benzodiazepine addiction and TA (substance misuse adult service) generally work with an older client group”

What on earth..???!!!  TA had a policy already in place, to work  with referrals from PF (young peoples substance misuse team).  This is because PF cannot themselves prescribe.  Basically this report was saying that they weren’t used to this type of situation and how to support someone like Jake.  Unbelievable!

There were various other things that I picked up on and asked questions about and then this…..

I skimmed though a particular paragraph over and over and then asked the question “So what about the letter from the GP to TA saying don’t hold back on prescribing”? “Where in this report is the acknowledgement of this letter/fax sent back in June 2015, just 2 months before Jake died”?

Ms F’s face became very serious and she asked “what letter”? “TA don’t have a letter, if they did it would be on their system and in the report” I replied that “Either the GP is lying or TA are lying”.  I made it very clear that I believed that this letter was sent by Jake’s GP to Dr. M at TA and that the instruction from the GP in this letter, could potentially have saved Jake’s life and that I want to know why it was not acted on and why there is no mention of this letter in the report.

Ms F. looked very stern, made some notes, and assured me she would look into this as a matter of urgency.  The Inquest was only a week away.  I made my way home with a copy of the report feeling like I still had far more questions than answers.

Over the next few days Ms F. and myself exchanged a number of emails and I remember becoming upset at how the Trust seemed to be remaining tight lipped on a number of issues.  Ms F. sent me a final email that read….

“I just want to support you……….”   That is honestly all it said, and it made me think that this individual is torn between covering the backside of the Mental Health Trust and being human.  I was lost for words, I really was.

The Inquest was now only 2 days away and I had still not had any response or answers about the missing letter.  

Friday 3rd December 2015 was the day of Jake’s Inquest at Stockport Coroners Court.  My anxiety levels must have been to the moon and back.  I will write a separate blog shortly to explain what happened at the Inquest.

Much Love.x

 

 

 

 

 

 

Know that your flight makes a difference

A beautiful poem written for Jake by one of his lovely and talented friends Hannah Dixon

I hope you know that your flight makes a difference.

I hope you know that you are worth more than the memories we have with you, that you are worth more than every ripple that your wake is creating, in previously still waters. That you are with us and will be with us again.  That you are not sleeping in life but becoming anew always,

That your butterfly effect is infinite, that you know that you are away from our plane leaf, flying where we cannot see you, far beyond the scope of I’s and though invisible to us now, you are more beautiful than any creature bound to this earth.

I hope you know  your flight makes a difference.

 

Suicide is no, longer a crime, so let’s all stop saying “Committed Suicide” spread the word.

Before 1961 it was a crime in the UK to commit suicide or to attempt to commit suicide. (It was never a criminal offence in Scotland and there have been and are still many different cultural and religious beliefs around the world).

The Suicide Act 1961 (9 & 10 Eliz 2 c 60) is an Act of the Parliament of the United Kingdom. It decriminalised the act of suicide in England and Wales so that those who failed in the attempt to kill themselves would no longer be prosecuted. (Wikipedia)

• If you committed suicide before 1961 you were denied a Christian burial and your body dumped in a pit with no clergy, no prayers and no mourners.
• The family of the deceased were stripped of their belongings which were then handed to the Crown.
• This led to the survivors (the family) being reduced to poverty and shame.
• If you attempted to commit suicide but survived, then you were (in most cases) prosecuted and thrown into Prison.
• Again the family of the survivor in prison had to live with the shame.

*I would guess that over the years and leading up to 1961 things were not quite so severe, as tolerance and understanding grew, perhaps due to the development of the medical profession).

The connotation of ‘commit’ is that someone has committed a crime or a sin, yet the phrase ‘commit’ when referring to suicide is still commonly used. It’s a phrase that I have myself used many times in the past without any thought whatsoever.

After Jake’s death on 23rd August 2015 I remember that I didn’t use the phrase committed suicide when telling people how he died. Not because I had any awareness of the stigma attached to it, but just that it seemed so harsh and I simply couldn’t bring myself to say it. I tended to say “He took his own life”

When I visit Jake’s grave and there are other families visiting new graves close by, we often chat and they see from Jake’s headstone how young he was and when they ask how he died, or was he ill, I tend to say “he was very poorly with mental health issues, possibly something like Bi-polar and that is why he died”. They get what I am saying. If we meet again and we chat more then I share more information if they ask me. It is hard to say out right that Jake took his own life or that he died by hanging. It breaks my heart.

So the point that I am hoping to make, writing this blog is that if we can all begin to build some awareness and understanding of how the phrase committed suicide contributes to the Stigma that still surrounds suicide.

There has already been an amazing job done through media campaigns, individuals and high profile celebrities to reduce stigma around mental health issues generally.

Let’s push forwards, towards changing the language we use when commenting on or reporting suicide could make a huge difference. I am aware that Papyrus, the Samaritans, Survivors of Bereavement by Suicide, Time to Change, CALM and many others have worked extremely hard to push this message to the powers that be and although it is clearly getting through, I am often still bewildered when I hear some news readers and some newspaper reports still using the phrase committed suicide.

Spread the word and let’s contribute towards reducing stigma and shame. Remember “took their own life” or “died by suicide” are far better phrases to use.

Little things can make such a difference.        Much love.x

“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.