"Falling through the cracks"

About: Hastings and Rother PCT Sussex Partnership NHS Foundation Trust

(as a relative),

This took place in 2006. My brother absconded from his home, faking his suicide in October 2005. In May 2006 he reappeared in our lives having been an inpatient following attempted suicide in January/February 2006 in a London borough. He was then found acting strangely on a beach in East Sussex, picked up by the police and returned to his psychiatrist under section. Although we hadn’t seen him since October 2005, because the place of safety was a police station, we were unable to see him again, or given any information about where he was returned to. He then turned up at my mum’s flat and decided to stay in our locality. In spite of our concerns about his mental health, he was discharged from the London borough as not needing psychiatric services as he DNA (did not attend) a clinic appointment even though he was on strong drugs. There was no handover to local psychiatric services in spite asking for this. He had a stash of drugs, got more from his new GP and committed suicide in June 2006.

After his suicide his psychiatrist from London contacted my mother and myself, which seemed to be a process of passing on the blame from himself in case we made a complaint. Whether or not my brother would have committed suicide if there were joined up services is a question that cannot be answered but just may be it wouldn’t have happened and maybe his family would not feel guilty at letting him down or feeling isolated and alone in an unknown situation.

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Response from Rachael Kenny, PALS and PPI Manager, Sussex Partnership NHS Foundation Trust

I am really sorry to hear about these tragic events- in order to offer some reassurance to you and other people reading the post I am going to find out more about what happens now in terms of transfers between different mental health care providers and how we take into account the views of families in the process. This may take a little time because of the Christmas break but I will be back in touch in the early New Year. If it would help to talk top our PALS service about what happened please do not hesitate to contact them on pals@sussexpartnership.nhs.uk

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Response from Rachael Kenny, PALS and PPI Manager, Sussex Partnership NHS Foundation Trust

Firstly I am sorry that there has been a delay in my reply – there was a computer glitch which meant that the reply I sent on 11/2 got lost.

I have spoken with my colleagues in East Sussex and found out what would have happened if the circumstances that you described occurred now. While this will not erase the past or the distress caused to you I hope it will offer some reassurance to you and other readers.

Your brother would have been admitted to the place of safety in the DoP (Department of Psychiatry) in Eastbourne which would have enabled you to visit him and him to be looked after in sympathetic circumstances while an assessment was made. Unless there were specific reasons not to (for example previously expressed wishes which we knew about from the service user not to share information) this assessment would involve you as family members to glean information to aid our risk assessment and to make appropriate plans for his immediate care.

It’s difficult to comment on why London discharged him due to a DNA or did not instigate a handover to local services but I would like to think that we would not do this with someone who presented a risk of suicide. The issue here is probably all around risk assessment – sadly sometimes we assess risk as low but it can change rapidly for some people and lead them to suicide. Transfers should involve families unless there is a good reason not to as they provide valuable perspectives for us when working with someone new and the trust has made public commitments to involving carers in care planning.

Good CPA, competent risk assessment and carer involvement are all factors that may have been helpful here, but it is difficult to judge on scant information. These days we also share the results of SUIs ( Serious Untoward Incidents- investigations which happen automatically after someone commits suicide) and that can be an opportunity for families to ask questions that they feel have not been addressed and of some comfort in terms of closure. I also would expect you to be made aware of the support groups that there are for carers in East Sussex.

It there is anything that you would like to follow up in detail the Patient Advice and Liaison Service in the trust would be very happy to help – they can be contacted on 01323 446 042 or pals@sussexpartnership.nhs.uk

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