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Start the conversation ‘Are you not feeling good today?’

Just ten weeks after Jake died the most surreal thing happened. It was November 2015, I set off for a walk on a route that I was familiar with along a nature trail. I was walking along deep in thought when I noticed something which made me pause and think. A young man was sat on a bridge facing the water. I noticed that he had a bottle of vodka in his hand and an elderly lady was talking to him. I thought that’s odd, but thought they must know each other. I carried on walking for a short time but something stopped me and I paused, looked back and watched the situation for a few moments. The elderly lady looked a bit troubled and she reluctantly walked away. The area was reasonably busy with dog walkers, joggers and local school children using the path as a short cut home. I decided to walk back towards the bridge and the young man. Don’t get me wrong it wasn’t high drama, there were railings that he was leaning against and it’s not a particularly high bridge. As I approached the young man he had his back to me and had earphones in. I looked around and everything just seemed normal, but I felt I had to ask if he was ok. I tapped him on the shoulder, he took out one of the earphones turned around and instantly tried to dismiss me by saying ‘there’s nothing you can do or say, just leave me.’ I tapped him on the shoulder again and said ‘are you not feeling good today’? I can still see the response and his face to this day. It was like a light switch, and he started to talk to me. I said to him ‘I lost my son to suicide 10 weeks ago and I have to live with it’. At this point I had his full attention. He started to tell me his situation, he had recently been released from Prison as he had been involved in a fight and served 18 months of a 3 year sentence. He had previously been a promising cricketer (he was 22) and he was struggling to fit in with his friends who he thought had all moved on. He told me that he had drank the vodka and had pills in his pocket (he showed me Sertraline). He also showed me that he had only taken one of the tablets since the prescription because he believed that his friends would think he was weird. He also said that this was the first time that he had actually taken action and that he was at stage 3 (I kind of knew what he meant). I said to him if you fall or jump from this bridge you will probably break both your legs and be hugely inconvenienced for weeks. At that point the elderly lady who had previously been talking to him appeared and she said to me there’s a bench over there. I suggested that we sit on the bench and assured him that I would continue to talk to him. He agreed and we sat down. To be honest I was getting worried because it was late afternoon and it was beginning to go dark, there were people around, but I thought my husband will wonder where I am. I asked him where he lived and when he told me it was literally a 10 minute walk (and the direction that I was heading). I said ‘would you like me to walk you home’? He said ‘would you mind? I smiled to myself and thought thank goodness for that. We started walking and his mood started to lift he seemed more upbeat and we chatted about more general things. As we got close to the avenue where he lived he suddenly stopped and said ‘oh no my Nan’s outside, she’ll have a heart attack if she knows what’s gone on’. I agreed to leave him at that point. I got my shopping and went home. My husband was at the door wondering where I had been. I told him the story feeling like I had done a good deed for the day, I felt quite hyped up. As the hours went by I started to worry and my safeguarding head kicked in. This was a young man, who left his home in the morning and did not know where that day was going to end and like I said it was not high drama and he wasn’t about to jump but he was not in a good place. I overheard some school kids say look at him attention seeking. I kept thinking that he is someone that could do it. I thought about contacting his probation officer, the Health Centre where he god his meds prescribed (he showed me the box) and I even thought, shall I go and speak to his mum. It was bothering me. My husband said to me you are far too vulnerable to get involved and just the chance meeting and the conversation that we had will stick with him and mean something. Over time I realised that this was right. Every time I walked close to where he lived I would look at the house and if the cat was sat on the bonnet of the car it would make me think that all was well in the world (no idea why). I actually passed him on the path about a year later and he said hello to me. I am not sure if he fully remembered me or it was just that I looked familiar. It made my day because he looked really well and upbeat. The family seem to have moved so I no longer need to look for the cat…lol. I will never forget that conversation or the look on his face when I asked ‘are you not feeling good today?’ I would like to think that the conversation means something to him too.

Missed Opportunities & Lessons Learned

How many times do we have to keep hearing these two phrases after Investigations and Inquests?  I received a copy of the Regulation 28 issued by the Coroner (recommendations to prevent further deaths) after Jake’s inquest Dec 2015.   The Regulation 28 was sent to 3 organisations, 1) The Chief Executive Greater Manchester West Mental Health Team, 2) The Medical Director of the Greater Manchester NHS Area Team and 3) The Practice Manager at a Health Centre which I will not name.  I was absolutely stunned to read in the Coroners Report, ‘This has happened before and lessons have not been learned’. I felt sick.  I studied very carefully, each of the 3 responses, I asked further questions and sought clarification.  What I found, I will include in future Blogs under various headings.  In my quest to find out what this comment (above) was referring to, I wrote to the Medical Director of NHS England (the organisation who this comment was directed at) and I asked the question “Why did the Coroner feel the need to include this in Jake’s Regulation 28?” The Medical Director of GM NHS Area Team wrote to me inviting me to meet with him.  I have to say that he was extremely generous with his time and I found him to be sincere.  He talked me through his responses and I felt re-assured that a thorough job had been done of responding to the Coroners findings and recommendations. He made the following recommendations:-

  1. A Dual Diagnosis Steering Group has been set up as a result of Jake’s death.
  2. Services that offer different services, but work together (shared care) need to improve their relationships and communication to avoid ambiguity (structured Management needed)
  3. The Community Mental Health Team (who had assessed Jake over the phone as high risk) have since Jake’s death been advised to attend jointly appointments with other organisations to improve engagement and assessment for Jake.  Such simple changes could make a huge difference to the lives of other.  It also in my opinion could save the NHS money. The Coroners words were ‘be more imaginative’. Jake never actually got to meet with the CMHT.  In fact I phoned them on Monday 24/08/15 to say that he was dead and would not be needing the appointment on Fri 28/08/15.
  4. A letter was sent to all GP’s outlining best practice when sending urgent correspondence. This is a contractual obligation which will be monitored by the Commissioner.
  5. Guidance on suicide prevention i.e. the need to always note the risk, irrespective of any previous understanding by the recipient (basically, don’t assume that other know the risk, always make it clear)
  6. Review policies and procedures for vulnerable patients who miss appointments
  7. To undertake a review of systems in place to track and to establish the lessons learned from any incidents and near misses.

Now back to  ‘This has happened before and lessons have not been learned’.   I asked Dr R. Patel a direct question “was this comment referring to an organisation (who I will not name) where a letter went missing?”  Dr. R. Patel was able to answer without breaking any confidentiality.  The comment was referring to the case of a vulnerable individual who moved address several times and the issue was with systems that are not joined up/updated.  I was able to stop being haunted by my own workings out in my head and was assured that this issue had been addressed and had no direct influence on Jake’s death.

As I continue to blog, one of the key things that am determined to do is to follow up point 7. (above) To undertake a review of systems in place to track and to establish the lessons learned from any incidents and near misses.  Regulation 28’s must not be dealt with in isolation for individuals.  They must be cross-referenced, monitored and audited.  Jake did well for a 23 year old young man to share everything with me his mother and without this insight Jake’s case would have been an open and shut case and there would not have been a Regulation 28 changes would not come about.

Dr R. Patel told me that after Jake’s Inquest the Coroner requested a meeting with him to discuss cases across GMW and she said to him “Your systems are baffling”  They are indeed……

#suicide prevention  #after suicide blog

Making sense of suicide

It has been almost 4 years since I lost my son Jake to suicide on 23rd August 2015.  Trying to save someone that you cannot save is soul destroying, it really is.  Jake was very poorly for 10 months before he died and it is difficult to  find the right words to fully describe what we both went through.  I weighed less than 7 stone before Jake died and as I use this site to Blog I will try to explain, remember and capture the chaos, the humour the warmth and the ‘much love’ that Jake and I shared.

I can say with absolute confidence that Jake trusted me and he knew that he could tell me anything (sometimes he told me more than a mother really wants to know).  I know that he 100% knew that it didn’t matter to me how long it took for him to get better, what mistakes he thought he had made and he knew that I would be there every step of the way and yet he took his own life.  This was extremely difficult for me to understand and leaves you with that all important ‘WHY?‘.  It wasn’t until a colleague at work pointed out to me that it mattered to him.  Knowing this and accepting this are two different things.   Perhaps a clue was when on one of our many visits to A&E when Jake was in crisis he told the Mental Health Nurse that he would not be able to carry on living because he was only 20% Jake and he needed to be 70% Jake so that he could work on being 100% Jake.

In the first few months after Jake died I remember someone saying to me that I should Blog and share my experiences because what I have seen, experienced and learned surely could help others.  I remember when Jake was so unwell, feeling totally alone and that it was my responsibility to save him and as much as I am a reasonably intelligent woman, who is confident and articulate, Jake took me into a world that I just did not understand.  I only know logical, rational, practical, caring, loving, these things just did not touch the sides and It felt like mission impossible at times and the battle with health services is another blog entirely.

So this is my first attempt at blogging and I hope that others can take something from my experiences and that the drive for awareness and change just gets stronger and the voice gets louder.