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Death By A Thousand Cuts: Report into the Tees, Esk and Wear Valleys NHS Foundation Trust “BPD+” Protocol

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Abstract

Investigative report into the “Protocol for the reduction of harm associated with suicidal behaviour, deliberate self harm and its treatment (for people with a diagnosis of borderline personality disorder and related conditions)”, also known as the “BPD+ Protocol”. The report details the history of the BPD+ Protocol within Tees, Esk and Wear Valleys NHS Foundation Trust, and considers its use in terms of English and European Law, national clinical guidelines and relevant academic research. There is extensive use of first-person testimony from TEWV patients, former patients, and family members. While the report focuses on Tees, Esk and Wear Valleys NHS Foundation Trust, the subjects discussed, the information gathered, and the implications of the findings are far reaching. 23/06/2022: Correction of minor errors in paragraph on page 235-236. The errors do not affect the understanding of the document. - 'crisis manager' change to 'team manager' - 'completely unknown to' change to 'barely knew'. - "are still in force today" change to "and remained in place for some time" - "remained unchanged since the plan was drawn up in 2016" change to "remained unchanged for a considerable period of time"
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Death By A Thousand Cuts: Report into the Tees, Esk and Wear Valleys NHS Foundation Trust
“BPD+” Protocol.
Lauren Langley
Eleanor Price
© Copyright 2022
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Contains some public sector information licensed under the Open Government Licence v3.0.
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Dedicated to the memory of:
Zoe Emma Zaremba: a kind, clever, talented young woman who was dearly loved by her family,
colleagues, and many friends. Zoe was passionate about so many things in her life, including
gymnastics, ballet, music, and cheerleading. She enjoyed baking, often knitted clothes for her
family’s new arrivals, and adored her guinea pigs. Zoe was failed by NHS mental health services
and died aged 25.
Richard St. John Mackenzie-O’Brien: a popular, thoughtful, caring young man who was deeply
loved by his family, girlfriend and many friends. Richard loved being outdoors, gardening, tree
climbing, and was training to be a tree surgeon. He was a huge supporter of Leeds United Football
Club, and enjoyed playing darts and caring for his budgies. Richard was failed by NHS mental
health services and died aged 19.
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Contents
Executive Summary ................................................................................................................... 9
Recommendations ....................................................................................................................13
Position Statement on “Borderline Personality Disorder” ...........................................................15
Report Terminology ..................................................................................................................16
Layout of the Report .................................................................................................................17
Acknowledgments .....................................................................................................................18
1.0 Aims of the Protocol .........................................................................................................19
2.0 Scope of the Protocol and Terminology ..........................................................................19
2.1 What are ‘similar long term issues’? ................................................................................20
2.1.1 Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD)
..........................................................................................................................................22
2.1.2 Post-Traumatic Stress Disorder (PTSD)/ Complex Post Traumatic Stress Disorder (C-
PTSD): ...............................................................................................................................23
2.2 Borderline Personality Disorder: Background Information ................................................26
2.2.1 The Danger of a Label...............................................................................................27
2.2.2 “BPD+”: Widening the Stigma ...................................................................................27
3.0 The Trust’s support for therapeutic risk taking ..............................................................30
3.1 Deaths in Hospital ...........................................................................................................30
3.2 Learning Lessons from Deaths ........................................................................................32
3.2.1 “Lessons Learnt”: An Empty Promise ........................................................................34
3.2.1.1 Stephenson Ward ...............................................................................................35
3.2.1.2 Inpatient Deaths Occurring off Hospital Property ................................................37
3.2.1.3 Patient Deaths in the Community ........................................................................39
3.3 There is No Evidence ......................................................................................................44
3.4 Positive Risk-Taking: An Introduction ..............................................................................45
3.4.1 BPD-Specific Positive Risk-Taking ............................................................................50
3.5 Developing and Maintaining a Culture of Negligence .......................................................54
3.5.1 West Lane Hospital ...................................................................................................57
3.5.1.1 Behind the Curtain ..............................................................................................59
3.5.1.2 The CAMHS Protocol .........................................................................................61
3.5.1.3 The Voices of West Lane ....................................................................................67
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4.0 Principle One: Purposeful Interventions .........................................................................85
4.1 Neo-recovery and a Strength-based Approach ................................................................85
4.2 “Suicidal Statements” ......................................................................................................88
4.3 Coercive Behaviour Modification .....................................................................................95
4.3.1 Parallels with ABA for Autism ....................................................................................97
4.3.2 Planned Ignoring as Ostracism of the Patient .......................................................... 101
5.0 Principle Two: Formulation ............................................................................................ 103
5.1 Attachment Theory ........................................................................................................ 105
5.2 Behaviour Modification, Revisited .................................................................................. 108
5.3 Patient Complaints ........................................................................................................ 109
5.3.1 Risk of Sexual Abuse by Staff ................................................................................. 113
5.3.2 Patient Complaints: Staff Culture ............................................................................ 116
5.4 Self-harm and Stigma .................................................................................................... 118
5.4.1 Self-harm: Negative Treatment Cycles .................................................................... 123
5.4.2 Self-stigmatisation in Hospital ................................................................................. 125
6.0 Principle Three: Precision in Thinking and Communicating about Self-Harm and
Suicidal Behaviours .............................................................................................................. 127
6.1 Functional Analysis ........................................................................................................ 129
6.1.1 Critical Analysis of FA Procedure for Suicide/Self-harm .......................................... 131
6.2 Imprecision in Thinking and Communicating about Self-Harm and Suicidal “Behaviours”
............................................................................................................................................ 136
6.2.1 Operant Suicidality/Self-harm ..................................................................................... 138
6.2.2 What if there is no “Chronic Pattern”? ......................................................................... 142
6.3 Behaviourism and BPD - What Interventions “should” look like ...................................... 144
6.4 Mental Distress or Anti-Social Behaviour? ..................................................................... 147
6.4.1 Anti-Social Behaviour, Crime and Policing Act 2014 ............................................... 150
6.4.1.1 Acceptable Behaviour Contracts ....................................................................... 151
6.4.1.2 Community Protection Notices .......................................................................... 155
6.4.1.3 Civil Injunctions ................................................................................................. 156
6.4.1.4 Criminal Behaviour Orders ................................................................................ 156
6.4.2 What is “Anti-Social” Behaviour Anyway? ............................................................... 157
6.4.3 Harm to Whom? ...................................................................................................... 158
6.4.4 Compulsory Treatment via the Back Door ............................................................... 159
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6.4.5 Iatrogenic Suicide: ‘Nobody wanted to hear me and protect me from mental health
services…’ ....................................................................................................................... 161
6.4.6 “It’s not Mental Health, it’s Behavioural” .................................................................. 167
6.5 Is there Clinical Evidence Supporting Punitive Measures for Attempted Suicide? .......... 177
6.5.1 No-Suicide Contracts .............................................................................................. 180
6.6 What does “Agreed in Advance” Actually Mean? ........................................................... 185
7.0 Principle Four: Multi dimensional risk assessment..................................................... 186
7.1 Multidimensional Risk Assessment: The Forgotten Dimensions .................................... 187
7.1.1 Minority Groups ....................................................................................................... 187
7.1.2 Vulnerability: A Trauma-Informed Approach ............................................................ 189
7.1.3 Medical Disempowerment: Power Dynamics .............................................................. 192
8.0 Principle Five: Patient Responsibility ............................................................................ 198
8.1 The Multiaxial System .................................................................................................... 198
8.2 “You Have the Capacity to Kill Yourself” ........................................................................ 200
8.2.1 ‘Well, because it obviously is your choice to… if you want to end your life. You have
capacity to make that decision’ ........................................................................................ 210
8.2.2 The Presumption of Capacity: The First Principle, but not the Last ......................... 211
8.2.2.1 The Two-Stage Statutory Test for Mental Capacity ........................................... 213
8.2.3 The Right to Self-Determination: The Freedom to Make “Unwise” Decisions .......... 218
8.2.3.1 Capacitous Adults can Decide to Die: Four Real Cases ................................... 218
8.2.4 Declaring Capacity is not the same as Assessing Capacity ..................................... 225
8.2.4.1 Human Rights ................................................................................................... 226
8.2.5 TEWV’s Systemic Abuse of the Presumption .......................................................... 231
8.2.6 Capacity in Crisis: Patients in the Shadow of the Protocol ....................................... 235
8.2.6.1 Authority, Interpretation and the Lawfulness of Anticipatory Declarations ......... 237
8.2.6.2 Judicial Authority and Precedent....................................................................... 239
8.2.7 This not about Capacity; this was never about Capacity.......................................... 245
8.2.7.1 The Mental Health Act 1983 ............................................................................. 248
8.2.7.1.1 Powers Provided to Healthcare Professionals ............................................ 250
8.2.7.1.2 Powers Provided to the Police .................................................................... 256
8.2.7.2 This is not about Capacity; this is about Power ................................................. 258
8.3 Responsibility and the Law ............................................................................................ 267
8.3.1 Prejudicial Practice .................................................................................................. 267
8.3.2 Shifting the Blame ................................................................................................... 268
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8.3.3 Duty of Care ............................................................................................................ 274
8.3.4 The Tort of Negligence ............................................................................................ 280
8.3.4.1 Article 2(1) Right to Life: The Patient’s Right to be Protected from Themselves 288
9.0 Principle Six: Consensus Decision Making .................................................................. 296
9.1 Informed Consent .......................................................................................................... 297
9.2 Groupthink and Dysfunctional Team Dynamics ............................................................. 301
10.0 Principle Seven: Less is More ...................................................................................... 303
10.1 Withholding Care to Avoid a “Disturbed” Identity .......................................................... 303
10.2 Once Again, No Evidence ........................................................................................... 305
10.2.1 6-72 Hour Admissions ........................................................................................... 309
10.3 Suicide and the Withdrawal of Care: Are Lessons being Learnt? ................................. 310
10.4 Individualism and the Rise of Self-Care in the NHS ..................................................... 312
10.5 “Dependence” on Services .......................................................................................... 316
11.0 Principle Eight: Defensible Documentation ................................................................ 322
11.1 Defensive and Self-interested Practice ........................................................................ 323
11.2 “Precise Support and Guidance” .................................................................................. 324
11.3 The Importance of Record-Keeping ............................................................................. 327
12.0 (The Protocol’s) References and Recommended Reading: ....................................... 328
12.1 A “Less is More” Approach to Evidence ....................................................................... 328
12.1.1 “The Fate of Borderline Patients” .......................................................................... 330
12.1.2 No Context Krawitz and Watson ............................................................................ 331
12.2 “BPD+” Could Mean Anyone ....................................................................................... 332
13.0 Aims of the Protocol: A Conclusion ............................................................................ 333
References ............................................................................................................................. 338
Appendix ................................................................................................................................. 377
Protocol - Adult Version 1: ................................................................................................... 377
Protocol - Adult Version 2: ................................................................................................... 384
Protocol - CAMHS Version: ................................................................................................. 384
Patient Testimony, Transcripts, Notes etc. .......................................................................... 385
Emails regarding access to adult and child Protocols .......................................................... 422
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Executive Summary
In 2012 Tees, Esk and Wear Valleys NHS Foundation Trust wrote, approved and deployed the
“Protocol for the reduction of harm associated with suicidal behaviour, deliberate self harm and
its treatment (for people with a diagnosis of borderline personality disorder and related
conditions)” as part of their prevailing operational framework. This internal document explicitly
advertised the Trust’s formal and unwavering support for the non-standard and experimental
approach to suicide and self-harm risk management in adult mental health services espoused
and embraced therein. As the title suggests, its clinical use concerned the assessment and
management of suicide and/or self-harm risk(s) in patients who were diagnosed with - or
appeared superficially to staff to fulfil the clinical stereotype of - borderline personality disorder
(BPD, also known as emotionally unstable personality disorder or EUPD). The associated
inclusion criteria were so wide that, in addition to BPD, a further 53 discrete psychiatric diagnoses
were also implicitly included in a novel diagnostic category named “BPD+”. The innumerable
patients subsequently exposed to this “protocol” were not informed of its existence, and
throughout most of its operational life the document deliberately remained inaccessible to the
public. However, under the powers of the Freedom of Information Act, this skin of secrecy was,
eventually, peeled asunder, forcibly propelling the protocol into the unavoidable glare of public
domain.
This clandestine model of care placed heavy emphasis on the notion that this entire patient
population would somehow experience some form of nebulous, long-term harm”, should they
ever receive the ‘familiar’, ‘common’, ‘caring’, ‘specialist’, ‘typical’, ‘socially expected’ and
‘intensive’ interventions provided for other patients in times of crisis. Staff were taught to “tolerate
the risk of death or serious harm to the patient by withholding such care, in the manifest absence
of any instruction to seek or obtain the patient’s consent before doing so. This “intervention” was
portrayed as an example of positive risk-taking. The Trust’s resolute endorsement of this
approach, termed “Less is More”, was explicitly parroted a number of times within the text, as was
the ominously forthright assertion that the Trust would continue to endorse this model of care,
even if patients died.
In 2014 the protocol was reviewed by the Trust, following which some of the more questionable
language was removed and replaced with heavily sanitised, largely euphemistic wording. The
main bulk of the text, however, remained entirely unchanged. Subsequently, between May 2014
and July 2020 the protocol remained in use within TEWV’s adult mental health services, but was
not reviewed or updated again. Additionally, a child and adolescent version of the protocol was
introduced for use within TEWV’s CAMHS facilities, with most sections lifted verbatim from the
2014 revision of the adult protocol. Between May 2016 and July 2020, this CAMHS protocol was
operationally deployed within TEWV’s child and adolescent mental health services. During this
time it was reviewed only once and, dubiously, only in the weeks immediately before its removal.
The protocol’s fundamental premise relies on the notion that all patients diagnosed with BPD, or
perceived (by staff) to fulfil the clinical stereotype of “BPD+”, are responsible for every decision
they make and every action they perform, including emotional responses to phenomena
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completely outside their sphere of control. In other words: whenever these patients claim they are
at risk of dying from suicide, they are, in fact, entirely capable of refraining from doing so. It follows
that, should such a patient attempt suicide, they are doing so “deliberately” and often as a means
of gaining some form of tangible reward from staff. The protocol indicates that by responding in a
caring or protective manner to situations of high risk, the “undesirable” behaviour being displayed
by the “BPD+” individual (an example used in the protocol is a patient telling staff they feel suicidal)
is reinforced in the individual who will then have no incentive to stop acting in this manner. The
protocol highlights that withholding ordinary, life-saving, interventions when someone is
displaying one of these “undesirable” behaviours (e.g. stating they feel suicidal) is “justifiable” in
nature, as the potential harms that could be experienced (e.g. death by suicide) are weighed
against the long-term goal of erasing these behaviours. In essence, the Protocol weaponises
“personal responsibility”, as a means of denying patients clinically appropriate care. Patients are
told they are entirely responsible for their distress and subsequent actions, but are covertly denied
any opportunity to make treatment choices for themselves. As such, “BPD+” patients are robbed
of their lawful right to access crisis care, whilst being held responsible for the potentially lethal
consequences of such.
This disingenuously false notion of patient “responsibility” has led to the formation of a clandestine
alliance between TEWV and local constabularies. Upon “deciding” a particular patient is not
sincere in their suicidal endeavours, the Trust may collude with police officers to threaten them
with legal action under the Anti-social Behaviour, Crime and Policing Act 2014. Patients who make
repeated attempts to end their life may subsequently find themselves presented with an
Acceptable Behaviour Contract compelling them to desist their suicidal behaviour under threat of
prosecution for, in effect, not dying.
Throughout the protocol, no evidence is provided by the Trust for this abject failure to provide
even the minimum standard of care to this group of patients. The principles of the protocol not
only contradict current academic evidence regarding effective management of suicide and self-
harm risks, but also fail to comply with NICE and other professional guidelines for good practice.
Moreover, the model of care espoused therein fundamentally violates the Trust’s statutory duties
with regard to upholding the principles of the European Convention on Human Rights, in
particular, the measures they must take to protect their patients’ Article 2(1) right to life. This
clinically unevidenced, unlawful and stigmatising doctrine essentially forms the groundwork for
the protocol’s ensuing methodology.
When compiling evidence the authors spoke to dozens of patients, carers, family members, and
staff/former staff across all Trust localities. Deeply troubling patterns of staff behaviour were
immediately apparent. Of most concern, a gross distortion of the ordinary clinical understanding
of suicidal ideation, suicide attempts, and risk of death by suicide, was evident across the entire
Trust. There is, it seems, a pervasive cultural belief to the effect that, if someone really wants to
end their life they won’t ask for help, they will just do it. The fatalistic notion that “actual” suicide
cannot be prevented subsequently “justifies” withholding care, because “if you’re going to do it,
nothing we do can stop you”. Patients from a variety of Trust services across all localities assert
that staff simply never learn how harmful these practices are, because when patients don’t die
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after being refused care, the belief that they weren’t really at risk of suicide is subsequently
reinforced. Conversely, should a patient actually die by suicide, their death is immediately
construed as an inevitable, unpreventable tragedy, because “if someone really wants to end their
life, they will always find a way”.
What’s more, not only are precariously suicidal patients having their requests for crisis care
denied, their needs are summarily dismissed with the notion that suicide is a choice they are at
liberty to make. This wholly erroneous understanding of patient autonomy forms the basis upon
which the Trust has either wilfully perverted or entirely ignored numerous aspects of statute,
common and European laws concerned with the protection of patients from negligence, neglect
and abuse. For example, a founding principle of the Mental Capacity Act 2005 is misappropriated
to fabricate a more authoritative-sounding version of the responsibility narrative, wherein patients
asking for help are told they legally “have the capacity” to kill themselves, thus staff are prohibited
from helping them.
Chillingly, the manner in which staff elect to dismiss patients who have either disclosed suicidal
feelings or survived attempted suicide, has effectively coached vulnerable adults and children into
serious and repeated attempts to end their lives. Patients seeking help may find themselves being
told that, if they were really suicidal they would act on their feelings and not call the crisis team;
that, if their suicide attempt was intended to end their life they would have taken more pills or
different, more lethal, pills; that, if they were genuine they would have isolated themselves; that,
if they weren’t attention-seeking they would have ensured no-one was aware of their plans.
Patients recount feeling that staff were daring them to kill themselves successfully; that staff have
goaded and pushed them into making further attempts, either with humiliating and degrading
remarks, or by suggesting “better” ways to go about it. We have even been told that, after a while,
suicide becomes a means of escaping the “care” of Tees, Esk and Wear Valleys NHS Foundation
Trust. The authors know of at least one young person who tragically ended their life after
repeatedly expressing such feelings.
In July 2020 both adult and child “BPD+” protocols were removed from use at the Trust. The new
Trust-wide risk assessment and management policy (subsequently deemed inadequate by the
CQC) instructs staff that they should no longer follow these protocols, but instead use their clinical
experience and “evidence bases relevant to the person’s specific situation” to inform their
practice. The authors find this deeply concerning: the culture of negligence embedded in the Trust
has not been addressed, and no assurances have been given that staff will not continue to use
protocol-esque models of care. By substituting policy for individual clinical opinion, the Trust puts
patients in the position of being unable to scrutinise the validity of clinical interventions, or to
examine the “evidence bases” being used to “inform” their care.
These patients and their families have not been offered an apology; they have not been offered
an explanation; nor have they been offered any form of review concerning why and how their care
could have fallen so far below the minimum clinical, ethical and legal standards expected from an
NHS Trust. On a systemic level, the deaths of patients subject to the protocol have yet to receive
the scrutiny of independent investigation or statutory inquiry.
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In the event of protocol-treated patients dying or being seriously injured, the Trust pledged to
undertake a retrospective review of their care, with the explicit guarantee that every one of the
Protocol’s principles would be considered as part of such. However, following a series of FOI
requests, the authors can reveal that TEWV have neglected to record whether this has ever taken
place. Indeed, after searching through all Trust-held records of serious incident reviews
concerning the deaths of inpatients diagnosed with BPD, the Trust admitted that not a single
review made reference to the protocol. As such, the only part of the protocol which comes close
to meeting the Trust’s statutory duties with regard to efficient regulatory oversight concerning
patient safety, is utterly meaningless. In effect, during its eight-year operational lifetime, TEWV
had absolutely no means of accurately monitoring the potentially devastating risks so obviously
incurred by the protocol’s wholly experimental approach. As such, the Trust simply cannot know
whether patients were receiving safe, high-quality and lawful care, or whether the protocol merely
resulted in them being neglected to death. To put it bluntly: it’s entirely possible that the protocol
is implicated in the preventable deaths of hundreds of patients yet, as TEWV declined to monitor
or record its usage we will, in all likelihood, never know.
The authors believe the protocol not only serves as a reflection of Trust culture, but also appears
to have encouraged and further propagated its singular ideology throughout disparate areas of
the Trust. This is tragically epitomised by the horrifying scandal erupting from within TEWVs
specialist children’s inpatient services at West Lane Hospital; the emerging details of which are
conspicuously resonant with the language, ideology and (discernable) repercussions entailed by
the protocol. The published accounts of former West Lane patients depict a clinical environment
replete with protocol-esque ideas, attitudes and strategies. Accordingly, the authors firmly believe
the “model of care” ostensibly “practiced” at West Lane, and explicitly noted by the CQC, is merely
a euphemistic reference to the principles espoused by both CAMHS and adult versions of the
protocol. In light of such, and of the narratives still emerging from the former CAMHS unit, it seems
the protocol may, in fact, be fundamentally embroiled in the cruelty and maltreatment experienced
by former West Lane patients.
With regard to the culture of risk management within TEWV, the authors sent FOI requests to
each NHS mental health Trust in England, enquiring as to whether any other Trust has (or has
ever had) a personality disorder specific risk management policy in place. Consequently, the
authors were appalled to discover that one other Trust in England is currently using TEWV’s BPD+
Protocol. Southern Health NHS Foundation Trust in Hampshire, widely described as a
“scandal-hit” mental health Trust, have had TEWV’s protocol in place since 2012. Since 2015, the
Trust has repeatedly appeared in national headlines in relation to multiple, preventable patient
deaths and safety failures, including the shocking failure to investigate the unexpected deaths of
over 1,000 patients in just 4 years. In 2017, the provider gained the notoriety of being the first
NHS trust to be prosecuted by the CQC specifically for failing to provide safe care to patients. In
the time since, Southern Health has been successfully prosecuted for systemic breaches of the
law a further two times, with each linked to the preventable deaths of vulnerable patients. At the
time of writing, Southern Health is now the subject of a public inquiry, concerning the preventable
deaths of a further five patients. The authors simply cannot dismiss this as mere coincidence. A
disgraced NHS provider at the centre of yet another, nationally reported patient safety scandal,
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just so happens to be the only other mental health Trust in England with this exact protocol in
place.
Ultimately, there is no evidence to suggest that withholding clinically appropriate care from
suicidal and/or self-harming patients as a means of forcing them to “take responsibility” for
themselves, is a safe, effective, or lawful intervention. There is, likewise, no evidence that
“ordinary” mental health interventions, such as hospitalisation, frequent community contact and
specialist support are especially unsafe or detrimental to this particular patient population.
Similarly, there is no evidence to indicate the protocol has actually succeeded in effectively
reducing harm to patients, increased rates of recovery, or reduced patient deaths. Indeed,
according to the patients subject to such, not only has the protocol failed to reduce harm, it has
actively caused harm. One such patient, Zoe Zaremba, died by suicide at the age of 25, after
enduring years of protocol-directed neglect and maltreatment. After her death in June 2020, Zoe’s
mother, Jean Zaremba, revealed that her daughter had come to see death as the only means of
escaping its devastating effect.
The following report draws eight years of protocol-associated failings into the foreground, and
endeavours to shed light on the wider culture of negligent and abusive practices within the Trust.
One of the most important aims was to give voice to the people silenced by TEWV, whilst
honouring and remembering those who have died under its care. The authors are grateful to have
been entrusted with the extensive written testimony of numerous TEWV patients (and relatives)
concerning their experiences of being “cared” for by the Trust: scans, photographs and
screenshots from those with access to their Trust patient records, copies of correspondence
between Trust staff and themselves, and transcripts of patient-recorded appointments with Trust
staff. This painfully honest testimony, while excruciating at times, provides incredible insight into
the practices of the Trust, which otherwise go unseen.
Overall, this is an emotive document, and likely to make mental health professionals feel
defensive and uncomfortable. We hope that professionals are able to sit with this discomfort and
allow themselves to hear the words of people who have experienced harm at the hands of mental
health services. Only by truly listening can we create meaningful change.
Recommendations
1. The authors support calls for an immediate statutory public inquiry into Tees, Esk and
Wear Valley NHS Foundation Trust.
2. The authors recommend an independent investigation be commissioned into TEWV’s
use of the “Protocol for the reduction of harm associated with suicidal behaviour,
deliberate self harm and its treatment (for people with a diagnosis of borderline personality
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disorder and related conditions)” and the “Protocol for the reduction of harm associated
with suicidal behaviour, deliberate self-harm and its treatment (for young people with a
diagnosis of borderline personality disorder and related conditions)” between 2012-2020.
We feel particular focus should be placed on:
a. The harm incurred (including deaths, serious injury, near misses, and
psychological harm)
b. Undertaking case reviews on behalf of each individual treated under the protocol
c. Asking why the protocol was not reviewed for 6 years
d. Uncovering how an NHS clinical policy that ignores national clinical guidelines,
breaches countless statutory provisions, and completely disregards the current
academic understanding of how best to support this patient population, was
allowed to be formally written, approved, published, and embedded across the
Trust.
3. The authors recommend an independent investigation be commissioned into the Trust’s
use of the Mental Capacity Act 2005, in particular their repeated misuse of the statutory
presumption of capacity to withhold care from extremely vulnerable individuals.
4. The authors recommend that the Trust immediately review their understanding of
a. Their legal and ethical duty of care, automatically owed to all patients
b. Their additional statutory duties with regard to upholding the European Convention
on Human Rights, in particular, the steps the Trust must take in protecting their
patients’ Article 2(1) right to life.
5. The authors recommend that the Trust immediately review the clinical use of positive
risk-taking within each of its services, particularly in regard to patients at high risk of suicide
and/or self-harm.
. 6. The authors recommend that the Trust immediately review the prevailing understanding
of staff, with regard to their legal and ethical duties to ensure informed consent has been
given by patients before undertaking any interventions or treatments, and the rights
patients have to choose/decline appropriate and available treatments.
7. The authors recommend the Trust immediately review their use of Acceptable Behaviour
Contracts which threaten suicidal patients with legal sanctions, including prosecution
under the Anti-Social Behaviour, Crime and Policing Act 2014, for actions such as
attempting suicide.
8. The authors recommend the Trust open an internal investigation into why the Trust
appears to fall far below the national average in upholding patient complaints.
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9. The authors recommend the Trust open an internal investigation into their personality
disorder diagnostic practices, including the practice of applying punitive diagnoses to
individuals that staff dislike; particularly to individuals who have made complaints,
individuals who engage in stigmatised behaviours, such as self-harm, and individuals who
are or may be autistic.
10. The authors recommend the Trust implement independent, externally provided staff
training and education, with the aim of challenging pejorative patient stereotypes, and
that they also look at ways the Trust can support patients harmed by high levels of mental
health stigma within services.
11. The authors recommend that the Trust implement a more comprehensive system in
which patient information, particularly diagnoses, and characteristics protected under the
Equality Act 2010, can be collated and analysed alongside clinical outcomes.
Position Statement on “Borderline Personality Disorder”
The authors of the report would like to make it clear that we stand in opposition to the diagnostic
label “borderline personality disorder” (also known as emotionally unstable personality disorder
or EUPD). While we use the term “BPD” throughout, discussing the academic, legal and clinical
understanding of its “treatment” and “management”, we staunchly object to people being labelled
as such.
“BPD” is one of the most highly stigmatised diagnostic labels in mental health services, frequently
used to implicitly justify the following:
The punishment of women, LGBT+ and gender non-conforming people for not fulfilling
societal expectations or traditional gender roles
The containment and silencing of the distress of people who have experienced trauma,
such as child abuse and sexual violence, so that others do not have to acknowledge the
wider societal implications of the source of the distress
The punishment or exclusion of “difficult” patients (people who are disliked by clinicians;
people who have made complaints about their care; people who engage in behaviours
that staff find uncomfortable, such as self-harm; people who aren’t “recovering” fast
enough; autistic people with mental health difficulties; people who are too “complex”; and
people who insist on surviving their suicide attempts)
The covert exclusion, or “off-rolling”, of people from services for financial reasons or to
meet targets
We profoundly disagree with the assertion that a person’s personality can be fundamentally
“disordered”, particularly when the difficulties experienced by such individuals are usually
associated with trauma, adversity, poverty, deprivation, social exclusion, and discrimination
against protected characteristics such as sexuality, gender identity, and disability.
16
Report Terminology
1. Content Warning. The report discusses many distressing and difficult topics, including,
but not limited to: suicide, suicide methods, self-harm, child abuse, child deaths, sexual
violence, domestic abuse, psychiatric abuse, physical restraint, sedation, gaslighting,
ABA, police involvement in mental health, medical neglect, psychiatric and psychological
experimentation on people, behaviour modification, medical coercion, etc. Please read
with caution.
2. After discussions with numerous individuals with lived experience, the authors arrived at
the terms “BPD-labelled person” and “person labelled with BPD” to describe people who
have been given a diagnosis of “BPD/EUPD”.
3. The authors chose to use identity-first language when discussing autism (‘autistic person’
rather than ‘person with autism’) as this is widely regarded as more acceptable within the
autistic community.
4. The authors make numerous references to the diagnostic criteria and clinical management
of mental health diagnoses throughout the report. These are used for illustrative purposes
and do not necessarily convey the personal or political beliefs of the authors regarding the
validity of the diagnosis or its management.
5. After discussions with numerous individuals with lived experience, the authors decided to
use the word ‘patient’ to describe people who access or who are under the care of mental
health services. This was a difficult decision to make, as many people had very strong
opinions on which words they preferred. Along with ‘patient’, the words suggested to us
were ‘client’, ‘service user’, ‘consumer’, ‘survivor’, ‘survivor of services’, ‘victim of services’,
‘recipient’, ‘Mad person’ and ‘hostage’. ‘Service user’, which is very commonly used by
services, was actually the least popular of the above. The most commonly suggested were
‘patient’, ‘client’ and ‘survivor’. We chose ‘patient’ as we feel, unlike ‘client’, the word
highlights the power dynamic and paternalism that exists in services; both of which are of
importance in this report. We also preferred ‘patient’ over ‘survivor’, as not everyone has
survived TEWV care.
6. Throughout the report we frequently use the word “staff” to describe people working within
the Trust who carry out abusive, negligent, or other forms of negative action towards
patients. The authors would like to make it clear that we do not believe all TEWV staff
members behave in this manner. Alongside appalling acts of cruelty and negligence, many
TEWV patients have also experienced helpful, healing, and positive actions from members
of staff. We believe that not only are these individual staff members responsible for a huge
amount of good, but that possessing the moral fibre to continue to do so in such a difficult
environment is a testament to their character. We also believe, in some situations, harms
may be unintended by staff, who are often working in difficult, unsupportive environments,
with inadequate training and poor management.
7. The report does not follow any one style of writing. In some areas it is more scientific and
objective in nature, while in others, the tone is more journalistic and informal. Where the
authors speculate rather than provide evidence, this is signposted.
17
Layout of the Report
This report is written in response to the following TEWV clinical directive:
‘Protocol for the reduction of harm associated with suicidal behaviour, deliberate self harm
and its treatment (for people with a diagnosis of borderline personality disorder and related
conditions)’
(henceforth ‘the Protocol’)
The Protocol’s introductory text is divided into three sections:
‘Aims of the Protocol’
‘Scope of the Protocol and Terminology’
‘The Trust’s Support for Therapeutic Risk Taking’
The main body is divided into eight “principles”:
1. ‘Purposeful Interventions’
2. ‘Formulation’
3. ‘Precision in Thinking and Communicating About Self Harm and Suicidal
Behaviours’
4. ‘Multi-Dimensional Risk Assessment’
5. ‘Patient Responsibility’
6. ‘Consensus Decision Making’
7. ‘Less is More’
8. ‘Defensible Documentation’
It ends with a short reference section and appendix.
We have not removed any of the Protocol, but have merely written into and around the Protocol
itself so that we are able to directly discuss what is written in each section. Occasionally, sections
of the Protocol have been moved out of order, with the aim of making the report easier to follow.
It is signposted throughout the report where this has occurred.
The Protocol is written in italics, and displayed in text boxes, for example:
Example box
Between 2012 and 2020 the Protocol was reviewed by the Trust on one occasion (2014) and
some changes were made to its content. Both versions (V1 and V2) of the Protocol are used in
the report and have been merged together. Where text was edited during the 2014 review, we
have highlighted this in the footnotes. Where text was added during the review, we have
highlighted this in the text with “(V2 only)”.
18
Both versions of the Protocol are available in the appendix, along with the child and adolescent
version. The authors strongly suggest reading the Protocol first, before reading the report.
Acknowledgments
The authors are indebted to the innumerable patients, ex-patients, relatives, carers, and bereaved
relatives/carers, who generously allowed us to draw on their harrowing experiences throughout.
We were deeply moved by the many stories we were told, detailing the countless lives upended,
tyrannized and (not infrequently) destroyed by their interaction with TEWV. We are forever
grateful for their honesty, their trust in us, and for the emotional labour entailed by their acutely
personal, and often painfully visceral, contributions. These experiences are the primary evidential
backbone of this document; the material foundation upon which the following claims, analyses,
discussions, and conclusions are (ultimately) based. Without you, this piece of work would not
exist. Thank you.
We are also immensely grateful for the support of Yor-Peer Support and several other groups for
individuals harmed by TEWV, for the parents of children harmed by TEWV, and for those
individuals/families bereaved by TEWV.
Specific thanks must go to Ellie, who has been utterly indispensable since the reports inception,
as a ceaseless source of encouragement, feedback, ideas, experience, and information. Her
unyielding determination and her tireless work in mental health policy, research, education, and
social care is truly inspiring.
In addition, we extend heartfelt thanks to the following individuals for their support and assistance:
Jean Zaremba, David Moore, Wendy Fleming-Smith, Amanda, Ruth Williams, Samantha Hartley,
Krista Langley, Mark Langley, Marie Langley, Elizabeth Whitehorn, and Tony Roberts.
Finally, though not directly involved in this project, we would like to acknowledge parties whose
published work was indispensably informative and/or fundamentally influential, including: Gillian
Proctor, Brenda Hale, Alex Ruck Keene, Chloe Beale, Joy Hibbins, Recovery in the Bin, Help
Faith Heal, and INQUEST.
19
(V1) Protocol for the management of clinical risk associated with suicidal behaviour and
deliberate self harm carried out by people with a diagnosis of borderline personality disorder
(BPD) and related conditions
(V2) Protocol for the reduction of harm associated with suicidal behaviour, deliberate self harm
and its treatment (for people with a diagnosis of borderline personality disorder and related
conditions)
1.0 Aims of the Protocol
The aims of the Protocol have been moved to the end of the report (Section 13.0 Aims of the
Protocol: A Conclusion), so that the aims can be more fully considered once the entire document
has been scrutinised.
2.0 Scope of the Protocol and Terminology
The protocol applies to care delivered in inpatient and community settings. It applies to people
who have a diagnosis of borderline personality disorder (BPD) and to people challenged by similar
long term issues of self harm, suicidal thinking and behaviour, emotional difficulties, and
difficulties with relationships. Such people may have one or more of a range of personality
disorder diagnoses. The term BPD+ will be used as shorthand for this group.
(V2 only) The term harm is used in the same way as in the Patient Safety Framework:
“We recognise that in supporting patients to make decisions about potential harm and how those
harms should be managed, it is necessary to see harms in the broadest sense to include:
Tangible harm -such as suicide, self-harm, falls, physical health deterioration,
medication adverse reactions, neglect and vulnerability.
Harder to define harm may include safeguarding, exploitation, or loss of : freedom,
humanity, privacy, control, liberty, self-determination, hopefulness, self-esteem,
dignity, optimism. (This list is not exhaustive).
Short-term harm (that might require physical healthcare or lead to an inability to
pursue one’s interests) and long-term harm, such as loss of confidence,
independence or aspiration.
Harm as a result of an act and / or of omission.
Harm to self and others. “
In 2019, in response to a patient’s online review of the Trust, TEWV confirmed that the Protocol
was not solely for use with people labelled with BPD/EUPD [1]:
20
“The trusts [sic] BPD protocol is used to support teams and service users when there is a
difference of opinion on key aspects of someone’s care. It does not mean the person who
is formulated through this framework has EUPD.”
While the Protocol opens with a limited description of which patients may be treated under its
principles, it fails to clarify which additional diagnoses might be entailed by the “+” in “BPD+”,
other than those who ‘may’ have another personality disorder diagnosis. According to the
inclusion criteria, the “+” includes anyone who experiences ‘long term’ issues of self-harm, suicidal
ideation, emotional difficulties, and difficulties with relationships, yet it fails to actually define such.
The phrase “long-term” has multiple definitions within a medical context. The NHS Data Dictionary
defines a long-term condition, including mental health conditions, as “one that cannot currently be
cured but can be controlled with the use of medication and/or other therapies[2]. Considering
the Protocol explicitly states ‘most people recover from BPD’ (pg.2 V1&2), the NHS definition of
long-term would seem to preclude BPD from being included in this BPD-specific protocol. Other
medical definitions of long-term include: a condition that lasts a year or more [3], a condition
lasting six months or more [4], and a condition that lasts longer than three months [5]. The
Protocol’s lack of clarity leaves the decision of what is “long-term” up to the individual
interpretation of staff.
2.1 What are ‘similar long term issues’?
The Protocol fails to provide an in-depth description of precisely what constitutes ‘similar’ issues
to BPD. To illustrate just how many different mental health diagnoses, neurodevelopmental
disorders and other conditions the Protocol could encompass, the authors cross referenced its
inclusion criteria (self-harm, suicidal ideation, “emotional difficulties”, and “relationship difficulties”)
with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
1
and other literature.
The following are all the DSM-5 diagnoses that could potentially be included within the “+”:
ADHD
Adjustment Disorder
Anorexia Nervosa
Antisocial Personality Disorder
Autism Spectrum Disorder
Binge-Eating Disorder
Bipolar I Disorder
Bipolar II Disorder
Body Dysmorphic Disorder
Bulimia Nervosa
Catatonia Associated with another Mental Disorder or Medical Condition
Conversion Disorder
Cyclothymic Disorder
1
The authors opted to use the DSM over the International Classification of Diseases (ICD) as the diagnosis “borderline personality
disorder” originates from the DSM, not the ICD.
21
Dependent Personality Disorder
Depersonalisation/Derealisation Disorder
Disruptive Mood Dysregulation Disorder
Dissociative Amnesia
Dissociative Identity Disorder
Gender Dysphoria
Generalised Anxiety Disorder
Histrionic Personality Disorder
Hypersomnolence Disorder
Insomnia Disorder
Intellectual Disability
Major Depressive Disorder
Major Neurocognitive Disorder
Obsessive Compulsive Disorder
Obsessive-Compulsive Personality Disorder
Other or Unspecified Anxiety Disorder
Other or Unspecified Dissociative Disorder
Other or Unspecified Feeding or Eating Disorder
Other or Unspecified Specified Personality Disorder
Other or Unspecified Trauma- and Stressor-Related Disorder
Other Specified Depressive Disorder
Other Specified Neurodevelopmental Disorder
Other Specified or Unspecified Obsessive-Compulsive and Related Disorder
Panic Disorder
Persistent Depressive Disorder
Posttraumatic Stress Disorder
Premenstrual Dysphoric Disorder
Psychotic Disorder
Schizoaffective Disorder
Schizoid Personality Disorder
Schizophrenia
Schizophreniform Disorder
Schizotypal personality Disorder
Separation Anxiety Disorder
Social Anxiety Disorder
Specific Learning Disorder
Specific Phobia
Substance-Related and Addictive Disorders
Tic Disorders
Trichotillomania
To treat 53 completely distinct conditions under a protocol evidently designed for a single
diagnosis, which is “evidenced” only by books and guidelines referring to that single diagnosis, is
22
a breach of the NHS Constitution
2
[6], and also ignores the treatment recommendations of the
National Institute for Health and Care Excellence (NICE) for each of these diagnoses.
To further illustrate the hazardous ambiguity of this Protocol, the authors have highlighted how
several of these diagnoses meet its “BPD+” inclusion criteria:
2.1.1 Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder
(ASD)
Criteria for inclusion in the Protocol:
Self-harm: Autistic people and people with ADHD are at an increased risk of self-
harm [7,8]. A study of adolescents with ADHD found that up to 71.4% of young
women questioned had engaged in self-harm [9]. Studies of autistic people show
50% have engaged in self-harm in their lifetime [10].
Suicidal ideation: “By early adulthood, ADHD is associated with an increased risk
of suicide attempt”.[11] ADHD has been found to increase the risk of death by
suicide in young men[12], while young women with ADHD are at the highest risk
for suicide attempts.[13] ASD has significantly higher rates of suicidal ideation than
the general population, with 66% of autistic people in one study reporting they had
contemplated suicide, and 35% reporting they had planned or attempted suicide
[14]. Autistic women have significantly higher rates of suicide than autistic men,
and the general population [15].
Emotional difficulties: People with ADHD may struggle to self-regulate their
emotions, experiencing high levels of emotions such as frustration, irritability,
impatience, hypersensitivity and excitability [16-18]. Autistic people may also
struggle to self-regulate their emotions, leading to severe anxiety, emotional
overwhelm, and high levels of emotional distress [19].
Relationship difficulties: The emotional experiences of people with ADHD can
result in decreased social and occupational functioning, elevated interpersonal
conflict, social rejection, neglect, and negative family interactions [20]. Difficulties
with interpersonal relationships are a diagnostic criterion of ASD [21].
The DSM-5 notes ADHD can easily be mistaken for a personality disorder, and that great care
must be taken to distinguish between them. It recommends ‘extended clinical observation’,
interviews, and a detailed history be taken specifically with this in mind [22]. NICE guidelines
highlight the importance of appropriately diagnosing those with ADHD, stating that ‘lack of
appropriate diagnosis and treatment adversely affects people's quality of life.’ [23] NICE goes on
to recommend mental health services form multidisciplinary specialist ADHD teams, with
2
which stipulates that patients have the right ‘to receive care and treatment that is appropriate to [them], meets [their] needs and
reflects [their] preferences
23
particular expertise in the management of ADHD, to provide treatment and consultation services
for people with ADHD who have complex needs [24].
Autistic people have high rates of self-harm and a high risk of death by suicide, yet suicidality in
autism is poorly understood, and highly under-researched [25]. Many autistic people classed as
“high functioning”
3
are misdiagnosed with mental health conditions, such as personality disorders
(particularly borderline personality disorder in autistic women), and schizophrenia [26-29]. It is
believed, due to the extremely high numbers of autistic people reporting suicidal feelings, there
are unique factors associated with suicidality in ASD [30]. Many studies find that ordinary mental
health services are not suitable for the treatment of mental health issues in autistic people and,
along with the recommendation of further research in this area, they also suggest that services
need to be adapted to meet the needs of neurodivergent people [31-35]. In its guidance on
management of mental health difficulties in autistic people, the Royal College of Psychiatrists
notes that the presence of autism may make the usual methods of assessing the risk of suicide
even more unreliable, and the ability [of some autistic people] to discuss suicidal ideas and plans
dispassionately makes it difficult to judge intent [36].
Accordingly, the Protocol does not take the differences in the psychopathology of ADHD/ASD
into account when discussing management of risk, despite its criteria directly including these
conditions. The Protocol does not include a single reference or piece of evidence that relates to
the management of risk in people diagnosed with ADHD or ASD, despite these conditions
displaying significantly higher rates of self-harm and/or suicide than the general population. Very
little is known about suicidality, its treatment, or risk management of suicidal behaviours in
neurodivergent people. Yet, the Trust felt confident enough in its understanding of the subject to
publish a suicide/self-harm risk management Protocol, the criteria of which directly includes
ADHD and ASD. TEWV’s ignorance of neurodivergence is confirmed by North Yorkshire County
Council’s Autism Matters 2020 report, which highlights the poor experiences many autistic people
have when attempting to access mental health support in North Yorkshire [37]. The findings note
a lack of accessible, reasonably adjusted, and specialist support in this area, and the dangers
associated with autistic people being ‘fitted into’ mainstream services.
2.1.2 Post-Traumatic Stress Disorder (PTSD)/ Complex Post Traumatic Stress Disorder (C-
PTSD):
Criteria for inclusion in the Protocol:
Self-harm: The DSM outlines the risk of self-harm in PTSD, noting that it falls
under ‘reckless or self-destructive behaviour’ [38], which is commonly seen in both
PTSD and C-PTSD. Studies of self-harm in C-PTSD and PTSD show high rates
overall (60-66%), with C-PTSD in particular displaying very high rates of self-harm
(91%) [39].
Suicidal ideation: Suicide risk is high in individuals with PTSD [40] and higher still
in those with C-PTSD [41]. Individuals with PTSD are found to be up to four times
3
Functioning labels are considered harmful and inaccurate by many autistic people, but are often used by services to categorise
levels of need. See: https://www.learningdisabilitytoday.co.uk/why-highlow-functioning-labels-are-hurtful-to-autistic-people
24
more likely to attempt suicide than people with other psychiatric conditions [42,43].
Multiple traumas have been found to increase the rate of suicidal ideation and the
rate of suicide attempts with each additional trauma [44].
Emotional difficulties: People with PTSD may experience negative alterations in
mood. The DSM states that PTSD may cause a persistent negative emotional
state which includes feelings of anger, fear, shame, guilt etc and a persistent
inability to experience positive emotions [45]. Complex PTSD is characterised in
the ICD-11 by severe and persistent emotional problems [46]. The diagnostic
criteria for both PTSD and C-PTSD includes a marked alteration in arousal
associated with the traumatic event/s, which includes irritable behaviour, angry
outbursts, and reckless or self-destructive behaviour [47,48].
Relationship difficulties: PTSD and C-PTSD are associated with high levels of
social and interpersonal difficulties. Individuals with these diagnoses often struggle
with anger, intimacy and/or sexual difficulties, trusting others, and difficulties
sustaining relationships, or feeling close to others [49,50].
Despite being a well-known diagnosis, PTSD is under recognised and under diagnosed in both
primary and secondary healthcare services; often being mislabelled as depression, anxiety, or
personality disorder [51-55]. Misdiagnosis or non-recognition of trauma related disorders are
considered to occur for a range of reasons. Within services, there is often a complete lack of
recognition that patients have experienced traumatic events, as many clinicians feel
uncomfortable asking patients about their history of trauma; particularly with subjects such as
child sexual abuse. On their PTSD patient information webpage, the Royal College of
Psychiatrists state PTSD may not be recognised by healthcare professionals because [d]octors
and other professionals are human. [We] may feel uncomfortable if [you] try to talk about
gruesome or horrifying events [56]. A systematic review in 2017 identified that most mental health
patients are never asked about traumas such as child abuse or neglect, and the majority of these
histories are never identified [57].
Diagnostic overshadowing
4
is also a major issue, particularly with diagnoses like personality
disorders as, once given, the label is extremely difficult to remove [58,59] and obscures the
underlying difficulties that person is experiencing [60-63]. Where clinicians are not comfortable
addressing or focusing on trauma, or where services don’t have practices in place to ensure a
trauma history is taken, studies have found that (as the majority of people with PTSD fulfil
diagnostic criteria for one or more other diagnoses) staff may be inclined to fill the diagnostic
space with a more established diagnosis [64]. There is likely to be a high risk of this occurring
under the care of TEWV, as staff are encouraged by the Protocol to consider common PTSD
difficulties as synonymous with borderline personality disorder.
Currently, there is much academic debate and discussion regarding the relationship between
trauma disorders, such as PTSD/C-PTSD, and BPD. Research has found BPD and PTSD share
4
Diagnostic overshadowing is a concept in healthcare where “once a diagnosis is made of a major condition […] there is a
tendency to attribute all other problems to that diagnosis, thereby leaving other co-existing conditions undiagnosed.Neuroglossary
- Diagnostic Overshadowing (Concept) [Internet]. Neurotrauma Law Nexus. 2020 [cited 9 October 2020]. Available from:
http://www.neurolaw.com/neuroglossary/#d
25
numerous clinical and biological features, including common neuropathological pathways [65] and
overlapping clinical symptoms [66]. It has been suggested that BPD should be reclassified as a
trauma-spectrum disorder, such as complex or developmental PTSD, due to the extremely high
number of BPD-labelled people who have experienced significant trauma (up to 92% [67,68]) [69].
When diagnosing personality disorders, clinicians often do not use formal ICD/DSM criteria or
structured diagnostic interviews but base their diagnosis on stereotypical personality disorder
symptoms (such as self-harm and suicidality [70,71]) or their negative personal feelings towards
the patient [72,73]. This can lead to the erroneous labelling of personality disorder in patients who
present with “similar” traits, such as people experiencing PTSD or C-PTSD [74,75].
Failing to recognise trauma related disorders, such as PTSD, can have serious deleterious effects
on both the mental and physical health, and overall quality of life of those left without support.
Unless adequately treated, PTSD usually persists over time, increasing the risk of suicide [76].
Untreated PTSD has been found to exacerbate patients’ distress, and can lead to high rates of
hypertension, elevated rates of cardiovascular disease and metabolic syndrome, pain disorders,
functional and emotional impairment, unemployment, and poor clinical outcomes for co-occurring
mental health issues [77-81].
Similarly to autism/ADHD, and despite the academic and clinical recognition of a high risk of
suicide in people with PTSD (including the suggestion that PTSD is one of the only psychiatric
disorders that predicts which individuals with suicidal ideation will transition to suicide attempts
[82]) there is little to no guidance available on how to treat people in crisis, and what types of
interventions are most effective. Once again, NICE guidelines are unable to provide more than a
cursory overview of risk in this patient population, with no suicide-specific guidance available.
Despite this, TEWV are so comfortable with their own understanding of PTSD and C-PTSD, they
have subsumed these diagnoses in a controversial and potentially lethal suicide and self-harm
risk management protocol, without a single piece of evidence to justify or explain why they think
this is appropriate.
**
Picking apart the inclusion criteria of this protocol to such an extent may seem overly pedantic,
but the authors felt it was important to highlight how wide the criteria are, so as to 1) effectively
illustrate just how many different people to whom this one intervention could be applied, 2) to call
attention to several specific patient groups who are being failed (other than those labelled with
BPD) and 3) to consider an important question if so many people fulfil the criteria, why do TEWV
staff not treat all patients with this protocol?
The authors feel the answer to this question lies within the caricature staff have in their minds, of
who “fits” the diagnosis of borderline personality disorder and who doesn’t.
26
2.2 Borderline Personality Disorder: Background Information
Borderline personality disorder (also known as “emotionally unstable personality disorder”
(EUPD)) is one of ten personality disorders listed in the DSM-V. In general, all personality
disorders are defined as stable, inflexible, and enduring patterns of thought, feeling and behaviour
which deviate from what would ordinarily be expected in a particular culture. This pattern of
unusual thought, feeling and behaviour must have started in adolescence or early adulthood, lead
to distress/impairment, and not be better explained by another diagnosis, condition, or use of
medication/substances.
BPD is described as a pervasive pattern of “instability”, which includes unstable relationships,
self-image and mood, and “marked impulsivity”. The DSM-V lists nine criteria, five or more of
which must be present for a diagnosis to be made:
Frantic efforts to avoid real or imagined abandonment
Unstable and intense interpersonal relationships
Persistently unstable self-image
Impulsivity in at least two areas which are potentially self-damaging (e.g. sex, substance
use, gambling etc)
Recurrent suicidality or self-harm
Mood swings
Chronic feelings of emptiness
Difficulty controlling anger, or inappropriate feelings of anger
Stress-related paranoia or dissociative symptoms
Internationally, BPD is recognised as a highly controversial and heavily criticised diagnostic label
[83-87]. There are significant academic concerns regarding: its indistinct diagnostic boundaries,
which make it difficult to distinguish from other conditions [88,89]; the inconsistent application of
numerous distinct structured diagnostic assessments [90,91]; the clinical reliance on inaccurate
unstructured assessments to diagnose it [92]; its stigmatising and punitive application [93-95]; its
reliability and validity as a construct [96,97] (the diagnosis itself has no core features
5
[98] and
256 different diagnosable presentations
6
); the clinical inconsistencies in its conception as an axis
2 disorder [99]; and its failure to coalesce as a coherent persistent personality group [100].
It is postulated that BPD could be a form of atypical depression, bipolar disorder, cyclothymia,
PTSD, complex-PTSD, neurodevelopmental disorder [101-108] or a manifestation of societys
repeated attempts to silence and pathologise the distress of women, and people who have
experienced sexual abuse or other forms of trauma [109,110] ( the label is given predominantly
to women (70-77%) [111], and trauma survivors (up to 92%) [112,113]).
5
In diagnoses which have “core” criteria, certain specific features within a larger list of criteria must be met for the diagnosis to be
given. In the DSM, BPD has nine diagnostic criteria, 5 of which must be met to give a diagnosis. None of the 9 criteria are
specifically necessary for the diagnosis, any 5 could be met.
6
Based upon the DSM-5 criteria of satisfying at least 5 out of 9 criteria (5 out of 9 = 126 different presentations; 6 out of 9 = 84
different presentations; 7 out of 9 = 36 presentations; 8 out of 9 = 9 different presentations; and 9 out of 9 = 1 presentation).
27
2.2.1 The Danger of a Label
Despite being a psychiatric construct, adopted and used ubiquitously by mental health services,
BPD is deeply stigmatised within mental health services. Many clinicians reveal their perception
of BPD-labelled patients, is of them being “manipulative”, “demanding”, “attention-seeking”,
“noncompliant”, “disruptive”, and not deserving of NHS resources [114-118]. However, there is,
in fact, very little evidence to suggest such unprofessional and, frankly, abhorrent attitudes are
informed by actual clinical behaviour [119,120].
Numerous mental health staff admit to “disliking”, “hating”, “detesting”, and wanting to avoid BPD-
labelled patients, or regarding them with contempt [121-125]. In one study, almost half the staff
surveyed reported that they would prefer not to work with BPD-labelled patients [126], with
another study finding that clinicians were more inclined to view BPD-labelled patients as more
responsible for their actions than other patient groups, and less genuinely unwell [127]. A paper
discussing Christian nurses’ attitudes towards patient’s labelled with BPD casually mentions an
incident on a ward where the nurses felt such rage towards a ventilator-dependent patient who
had been labelled with BPD that they actually switched off his ventilator during the night [128]. A
common theme within healthcare services is that BPD-labelled patients are not considered
unwell, rather, their distress is merely a “behavioural” issue [129-131].
Within mental health services, personality disorders are frequently used as a “dustbin” for patients
who are difficult to diagnose; patients who present with “problematic” behaviour [132,133];
patients that clinicians dislike, or those they perceive to be critical of their practice [134,135].
Shockingly, (and illustrative of the widespread, deeply embedded stigma within healthcare
services) pejorative terms, such as “manipulative”, “attention-seeking”, and “psychopathic”, are
actually coded into the national NHS Emergency Care Data Set as search terms for the
personality disorder diagnosis [136].
2.2.2 “BPD+”: Widening the Stigma
By widening the criteria of the Protocol to include individuals who do not have a diagnosis of BPD,
but who subjectively seem to experience “similar issues”, TEWV is essentially giving license to
staff members to label any and all “apparent” personality disorder patients as such, even where
they do not meet diagnostic criteria. Patients casually profiled as subjectively fitting the BPD
caricature will, most likely, be those perceived by staff to be “difficult”, “treatment resistant”,
“complex”, and otherwise “undesirable”
7
[137]. Given the Protocol is entirely concerned with
withholding normal interventions people have a right to expect when they are at risk of suicide or
self-harm, the nebulous wording of the inclusion criteria places so-called “undesirable” patients at
risk of being excluded from services, based solely on the fallacious and pejorative beliefs of staff.
7
The caricature creates a problem for patients, as those who have the diagnosis of BPD are perceived by staff to display
stigmatised behaviours, even if they don’t, and patients who do display the stigmatised behaviours are perceived to have the
diagnosis, even if they don’t meet the diagnostic criteria.
28
In the 1970’s, the Rosenhan experiment reportedly placed fake patients inside a number of
psychiatric hospitals, with a presenting history that elicited a diagnosis of schizophrenia [138].
Although these patients” had no mental health difficulties, and throughout their time as inpatients
spoke and acted as they normally would, the study found the label of schizophrenia was so
overpowering, staff often entirely overlooked and profoundly misinterpreted ordinary behaviours.
The powerful effect of this diagnostic label led clinicians to distort the patients’ developmental
histories and incorrectly interpret relationship dynamics to be consistent with the diagnosis of
schizophrenia. By covering such a large and diverse group of patients with a single diagnostic
label, TEWV is encouraging staff to fall into these same behaviours; perceiving any and all patient
behaviours to be confirmation of the label.
Though the Protocol does not formally ascribe a clinical diagnosis to anyone, it overtly claims the
difficulties listed in its inclusion criteria are synonymous with BPD: repeatedly using the phrase
‘people with a diagnosis of BPD+’ throughout. Yet, “BPD+” is not, and nor has it ever been, a
recognised or legitimate diagnosis. This fabricated diagnostic category does not provide clarity
to the treatment planning and critical thinking of care teams, but instead creates an illusion of
homogeneity in those it cloaks, then used to justify a one size fits all approach to risk
management. As described by Reiser and Levenson: ‘the illusion is destructive. By treating all
patients as borderline subjects and failing in the process to see their individual features,
[clinicians] soon find that none of their patients are getting any better. Such [clinicians] are then
confirmed in their opinion that borderline patients are untreatable.’ [139]
BPD is one of the most (if not the most) highly stigmatised psychiatric diagnostic labels in
existence
8
[140]. By widening the BPD criteria, the Trust also widens the scope of the stigma
attached to it, encouraging further iatrogenic harm. Studies find that staff judge BPD-labelled
patients more negatively than patients not labelled as such, even where both display the exact
same behaviours [141,142]. Similarly, it's been observed that, when staff hold prejudiced views
about patients based upon the negative stereotypes of their diagnostic label, they may behave in
a discriminatory manner even before meeting the patient [143]. Essentially, stigma is a cue, which
serves to evoke subsequent prejudice and discrimination [144], dehumanising the stigmatised
group [145,146]. As noted by Murrow and Murrow, dehumanisation is associated with reduced
empathy for the pain of victims and with psychological and legal denial of their human rights’
[147].
In its National Risk Management Programme, the Department of Health instructs that ‘negative
and judgemental labels must be avoided, as they are a barrier to collaboration.’ [148]. Far from
acknowledging this guidance, thereupon ensuring Trust protocols do not use stigmatising and
pejorative labels, TEWV encourages staff to perceive certain behaviours as inherently “BPD”, and
to assign “BPD+” to individuals displaying these behaviours. As the inclusion criteria for “BPD+”
are so ill-defined, almost any patient staff do not want to interact with could be included. Other
mental health Trusts in England explicitly guard against staff equating particular traits or
8
A fact that will not have been lost on the Trust when creating this Protocol
29
behaviours with personality disorder diagnoses. In its Clinical Risk Strategy, Cumbria,
Northumberland, Tyne and Wear NHS Foundation Trust state [149]:
“The language used for understanding and working with personality disorder needs to be
reflected upon, as this may contain unhelpful assumptions or negative attitudes […].
Similarly, it is important to not equate “self-harm”, “chronically suicidal” or “cluster 8”
with a definitive diagnosable personality disorder unless these are checked out firstly with
high quality screening, assessment and scaffolding and clinical supervision.”
The manner in which the Protocol extends the BPD label to cover such a wide range of people is
a red flag regarding TEWV’s staff culture in relation to how certain patients and their difficulties
are understood. Indeed, the Trust’s zeal to identify personality disorders in their patients has led
to significantly higher numbers of these disorders being perceived in their patients than in patients
nationally. A local evaluation of the patient population, undertaken as part of the development of
their allegedly “trauma-informed” services, reported that the Trust felt 86% of patients surveyed
had ‘undiagnosed personality disorder’ [150]. Large scale studies measuring the (apparent)
prevalence of personality disorders in secondary care consistently find the rates to be between
30-50% [151-153], while other studies find clinicians frequently make inaccurate diagnoses of
personality disorders, based upon stereotypical symptoms or behaviour viewed in appointments,
rather than diagnostic criteria [154]. An incidental finding, made by a study looking at PTSD in
BPD-labelled patients, reported that, when reviewed, only 12% of the BPD-labelled patients
involved actually met DSM diagnostic criteria for BPD [155]. The indiscriminate nature of the
Protocol’s inclusion criteria, and subsequent labelling of all patients captured by it as “BPD+”,
strongly suggests that the Trust purposefully sees personality disorders everywhere, thus staff
may be more likely to experience confirmation bias: attributing emotional distress, self-harm, and
suicidal ideation to “personality disorder”, rather than another diagnosis or aetiology.
They diagnosed everyone with EUPD in [West Park] hospital. They tried medication
and for some did ECT and if it didn’t help they said “it’s just your personality” and
discharged them with an EUPD diagnosis. [..] I was in [West Park] for several months and
there were girls with PTSD, depression, bipolar, all re-diagnosed with EUPD and
discharged.”
- TEWV Patient (bold ours)
“The crisis team psychiatrist said he wasn't diagnosing her with a personality disorder
because she had only been unwell a really short time and didn’t fulfil the criteria so it was
likely to be something else, but the rest of the staff didn’t get that memo and kept saying
she had EUPD, even writing it in her notes. The inpatient staff were like it too - the nurses
and HCAs - it was like they really wanted her to have EUPD because they couldn’t
understand her any other way. Eventually, the psychiatrist, despite saying she didn’t
fulfil the criteria, started to consider EUPD because everyone else was.”
- Sister of TEWV patient (bold ours)
30
Every single one of my friends who is treated by TEWV has a diagnosis of a
personality disorder. Mostly EUPD, but some others too and also EUPD traits.
Personally I think its done on purpose because once you are diagnosed with EUPD
nobody takes you seriously any more. There are some really big problems in the hospitals
and in the community and crisis teams, so lots of people make complaints. With EUPD
noone has to take those complaints seriously and they can also discharge you by
saying being in hospital are making you more ill.”
- Former TEWV Patient (bold ours)
It’s hardly surprising the Trust believes 86% of its patients have ‘undiagnosed personality
disorder’, when its policies and protocols describe a vague, undefined, and widely applicable
collection of issues, such as ‘difficulties with relationships’, as being synonymous with borderline
personality disorder. By marking so many patients with this imaginary diagnosis of “BPD+”, TEWV
is failing in its duties to avoid the dangerous iatrogenic effects of stigmatised labels and provide
patients with appropriate care.
3.0 The Trust’s support for therapeutic risk taking
9
The Trust recognises that people with a diagnosis of borderline personality disorder (and other
people for who deliberate self harm and/or suicidal thinking is present for long periods of time)
are at very high lifetime risk of death or serious injury as a result of their own actions. (Stone 1990)
Reliably predicting if a person with a diagnosis of BPD+ will kill themselves in a given situation is
not possible given the current development of psychiatry and psychology (Paris 2008), partly
because the proportion of self harm events that end in actual suicide is very low. (Stone 1990)
People will kill or severely injure themselves even when very competent care is being provided.
3.1 Deaths in Hospital
The Protocol explicitly states it is written for both hospital inpatients and patients in the community.
Though the authors agree it is not possible for mental health services to keep their community
patients 100% safe, hospital inpatients should categorically not be able to ‘kill or severely injure
themselves’ when in receipt of ‘very competent care’.
In 2012, the Government published its National Suicide Prevention Strategy (NSPS), which
outlined key areas for action in reducing overall rates of suicide in England, specifically stating
‘suicide is not inevitable’ [156]. In 2017, the House of Commons Health Select Committee’s inquiry
into suicide prevention recommended improvements to the implementation of the NSPS, to which
9
In version 2 of the protocol, the heading is changed to “The Trust’s support for a comprehensive approach to harm reduction
31
the government responded by implementing a Cross-Government Suicide Prevention Workplan
[157,158]. A key area of focus was to ensure every NHS mental health trust had a “zero-suicide”
ambition plan implemented by the end of 2018/19. To support this initiative, the government
granted funding to the Zero Suicide Alliance, which aims to help reduce suicides across the NHS,
and bring inpatient suicides down to zero [159]. The Secretary of State for Health and Social Care
announced the funding was a vital step forward in reducing inpatient suicide, stating ‘every suicide
is a preventable death’ [160]. Accordingly, in its 2018/19 Annual Report, TEWV announced that
during the 2018/19 time period the Trust had developed a “zero inpatient suicide plan” based
upon the recommendations from the latest National Confidential Inquiry into Suicide and Homicide
in Mental Health report [161].
Regardless, the Protocol’s fatalistic approach towards suicide prevention, a sentiment echoed
throughout many departments within TEWV, directly contradicts the zero suicide strategies
implemented by the government and, bizarrely, the Trust itself. As already stated, inpatients
should not be able to kill themselves where ‘very competent care’ is provided. That the Trust felt
comfortable publishing such a statement in a protocol concerned with the management of suicide
risk, is not only utterly reprehensible, but is also indicates a general staff culture of contempt for
statutory duties, professional obligations and a callous indifference for the lives of their patients.
As illustrated by the following short excerpt (taken from a transcript of a recorded conversation
between a TEWV patient and two TEWV crisis team staff members) the belief that inpatient
deaths are “inevitable” is not only insidiously prevalent within the Trust, but is actually used to
withhold care from vulnerable patients:
Patient: ‘I’m going to harm myself tonight. [...] You’ve said what you can offer: you can
come and talk to me and ask me questions and..and that’s what you can do. And if I don’t
engage with that then you can’t, and if I kill myself, that is a decision I’m able to make.
That is what I understand by what you’ve told me.’
TEWV Crisis Team 1: ‘Well, when you are struggling with that, you know. If you’re going
to do whatever you’re planning on doing. You know, ring them, ring the crisis team.’
Patient: ‘Why would I?’
TEWV Crisis Team 1: ‘when you’re struggling at that moment in time.’
Patient: ‘Why would I?’
TEWV Crisis Team 2: ‘Because we hope that people want to live, basically. That’s our
hope. That people want… people want to live. And we can try and instill some hope.’
Patient: ‘Well I’ve told you I’m going to harm myself tonight.’
TEWV Crisis Team 2: ‘But if someone decides, then being in hospital can’t stop that.
Honestly, if someone wants to end their life, they end their life and it doesn’t matter
where they are, [patient name]. And we can’t prevent that.
32
Patient: So suicide can’t be prevented?
TEWV Crisis Team 2: ‘other than we call the police and get you incarcerated
somewhere which in this society doesn’t happen. You know, ..there’s..there’s very little
that we can do.
Transcript of a recorded conversation between a TEWV patient recently discharged from
hospital and two TEWV crisis team staff members
As later discussed in detail
10
, TEWV unequivocally owes all patients an explicit statutory duty of
care from the very moment they engage with the Trust. Principally, such a duty applies to all
members of staff involved in the patient’s care. Thus, should the patient experience any harm
causally associated with a breach of said duty, the Trust and its staff are responsible for the
consequences. The authors recommend the Trust refresh their understanding of the duty of care
they owe patients, and the additional statutory duties they have to uphold the principles of the
European Convention on Human Rights, in particular, the measures the Trust must take to protect
their patients’ Article 2(1) right to life.
3.2 Learning Lessons from Deaths
The Trust recognises that, in such tragic circumstances, it is important that the care is reviewed
to consider whether any lessons can be learnt, and that patients, their families and staff are well
supported during the review. The review will differentiate between contributory and incidental
findings and will clearly state where good practice is identified. The principles in this protocol will
be considered during the review.
In search of more detail regarding this Protocol-specific serious incident “review” promised above,
the authors submitted a Freedom of Information (FOI) request [162] to TEWV, specifically
enquiring how often the Protocol’s principles have been considered in such reviews, how many
patients have died whilst being treated under the Protocol, and what, if any, Protocol-specific
conclusions have been reached during such reviews. Recall, that the Protocol repeatedly
emphasises the ‘very high lifetime risk of death or serious injury’ occurring within this patient
population, yet unilaterally advocates risk-taking care plans that ‘play the long game’ (i.e.
“tolerating” this very high risk in favour of some nebulous long-term gain), and repeatedly stresses
the Trust’s ‘support’ for such risk-taking, which we are assured will continue to be provided ‘even
when tragic events occur’. In light of the Trust’s appetite for placing patients at mortal risk without
their consent, one would expect meticulous records to be kept along the lines of the questions
asked in the FOI request. As such, the authors were incredibly disturbed at what their request
actually revealed:
The Trust has failed to centrally record whether the Protocol has ever been examined
during any serious incident reviews
10
8.0 Principle Five: Patient Responsibility
33
The Trust has neglected to record the number of patient deaths that have occurred while
being treated under this protocol, for the entirety of its (almost) decade-long period of use
in clinical practice (“We do not record a correlation between procedures/policies and
protocols and deaths.” [163])
Of the serious incident reviews retained by the Trust following the deaths of inpatients
labelled with BPD, there was absolutely no mention of the Protocol’s existence or usage
in any review.
All in all, there is no record of the Protocol ever being considered or scrutinised in a critical light
following any manner of serious incident. It is also painfully clear that TEWV have absolutely no
idea how much harm patients might have endured as a result of their reckless approach to risk
management. Likewise, despite the Protocol’s feeble virtue-signalling regarding staff
documentation of their apparently ‘well considered decisions’ to deny care to suicidal patients, we
discover that the Trust can’t even be bothered to record Protocol-specific mortality statistics, let
alone learn from them. Finally, it is extremely suspicious to find the Protocol was given zero
consideration during any of the serious incident reviews following the deaths of inpatients labelled
with BPD
11
. The Protocol absolutely was in use while these patients were in the “care” of the Trust
and, as the document itself states: The protocol applies to care delivered in inpatient and
community settings. It applies to people who have a diagnosis of borderline personality
disorder (BPD)[.]” (Pg. 1 V1&2). Accordingly, the authors can see absolutely no reason why the
Protocol would not have been used to manage the risk of self-harm and/or suicide in such
patients
12
. It is, afterall, the document for managing BPD-specific patient risk.
Overall, the authors are extremely disturbed by these frankly shocking revelations. In essence,
TEWV have continued to use a Protocol which, by their own acknowledgement, empowers staff
to make life-threatening risk-taking decisions, on behalf of patients already 400 times more likely
to die by suicide (when compared to the general population) [164], without the patient’s consent.
Therein, the only part of the document that comes close to meeting the Trust’s statutory duties
with regard to efficient regulatory oversight concerning patient safety, is the part promising to
consider ‘whether any lessons can be learnt’ following a ‘tragic event’ (i.e. patient death), with the
specific promise that the Protocol’s principles be reviewed as part of the ensuing serious incident
review. Thus, not only has the Trust failed to keep explicit promises regarding review of the
Protocol’s principles with specific regard to patient safety, in failing to record the necessary
protocol-specific statistics, the Trust has ensured that a critique of the Protocol’s safety record is
all but impossible without an extensive, time-consuming clinical record search. Still, this assumes
the Trust has actually bothered to record the Protocol’s use in the records of every patient subject
to it which, given their seemingly selective approach to record-keeping, doesn’t appear likely.
At best, these findings are highly suggestive of a recklessly idle culture of laissez-faire risk-taking,
wherein the Trust affords staff the complete freedom to take unnecessary, unjustifiable risks with
11
The FOI requested data from the Protocol’s publication (7th June 2012) onwards, however, TEWV were unable to produce more
than five years’ worth, as they stated their updated systems did not retain serious incident records from before October 2015.
12
Particularly in light of the relatively higher level of risk presented by patients unwell enough to actually be considered for
admission, given that our already dwindling, drastically overstretched inpatient mental health services are still being driven into
oblivion by the neoliberal austerity-motivated “reforms” of the last decade or so.
34
patients' lives. Indeed, consider that, in neglecting to record these statistics, the Trust has ensured
an accurate assessment both of the Protocol’s overall safety record, the safety of its principles,
and its potential for inflicting avoidable and foreseeable risks of death or serious injury on patients,
is all but impossible. Putting it bluntly, the Trust has wilfully empowered its staff to play God with
patients’ lives, in that it continued to promote the Protocol’s obscenely reckless approach, whilst
knowing they had absolutely no means of accurately monitoring the potentially devastating risks
this approach so obviously incurs, and no means of ensuring patients treated under the Protocol
are receiving safe, high-quality and lawful care. Accordingly, it seems the Trust’s supposed
commitment to identifying ‘lessons [to] be learnt’ is little but an empty promise.
In the original FOI request, the authors had requested 15 years’ worth of patient death statistics.
In response, the authors were told that the Trust’s current version of Datix (an electronic incident
reporting system adopted widely within NHS services), mysteriously “does not hold the previous
15 years data”. The only explanation offered was that it was “due to a new reporting system that
was implemented in the Trust in 2015” (Datix) [165,166]. As such, the authors only received the
last 5 years’ worth of data (from October 2015 onwards). In light of such, the authors have no
choice but to assume the Trust only has the last 5 years’ worth of adverse incident data in their
records, including (inter alia) patient deaths, incidents causing harm to patients, and near-miss
events
13
. As such, not only have TEWV failed to provide an adequate regulatory framework
specifically regarding the safety of patients treated under the Protocol during the past 8 years, but
the integrity and efficiency of their trust-wide regulatory framework appears inadequate.
Additionally, either their management of patient records is so incompetent they genuinely did
manage to lose all of their data in one day during October 2015, or they are not being truthful
about their access to such. Either way, neither possibility speaks of the robust, functional
regulatory framework the Trust are legally obliged to have in place.
3.2.1 “Lessons Learnt”: An Empty Promise
When patients die under the care of mental health trusts, it’s usual for promises to be made
regarding the assurance that processes, policies, and practices have been reviewed. Where
failings are identified, Trusts typically pledge to make whatever changes are necessary to ensure
no more patients die.
Whilst gathering evidence, the authors collected and reviewed newspaper articles, independent
investigations, and coroner’s reports from between 2006-2021, concerning the deaths of 85
people who had used TEWV’s services. Accordingly, the authors were able to identify repeated
themes in these deaths, including:
Inadequate risk assessment and management
13
The authors find this difficult to believe. Particularly as, on the same day the Trust gave their final response to this FOI, they also
answered another of the authors’ FOI’s, by providing a copy of a quasi-external report reviewing 15 serious incidents taking place
between 2015-16. This report, published internally in 2017, contained serious incident findings from February 2015- October 2015, a
time TEWV are suggesting they no longer hold records for.
35
Consistent underestimation of patient risk and/or dismissal of self-reported risk level
Poor communication between staff
Failure to listen to the concerns of carers/family/friends
Unsafe ward environments (including environmental risk/observations missed)
Poor record keeping and management of records
39 of these patients died between January 2018 and April 2021, eight of whom were teenagers.
The failings listed above, all of which date back to when TEWV was first established, were present
in many of these recent deaths. This transpired to be a rather fraught process for the authors. To
read the historical post-inquest statements made by countless preventably bereaved families
regarding their relief, their comfort or their gratefulness at hearing TEWV’s promise to ensure no
further preventable deaths occur, whilst knowing that changes were not made and patients
continued, and continue, to die entirely preventable deaths was truly harrowing. The lasting
impression is that, ultimately, TEWV assigns no value to the lives of the people it is commissioned
to care for. Nothing says “you are worthless” more than repeated inaction following the deaths of
patients, which then allows for further deaths. The following sections consider just some of the
many people who have died under TEWV’s care, with specific focus on Stephenson ward;
inpatients who died while off Trust wards; and community patients.
Please note: the following contains graphic descriptions of individual suicides, including suicide
methods and extracts from suicide notes.
3.2.1.1 Stephenson Ward
On September 24th 2006, Jonathan Ferguson, 25, died on Stephenson ward of the University
Hospital of North Tees. Jonathan, who was supposed to be on 10-minute observations, died after
upending his bed and hanging himself from the frame with his sheets [167]. At inquest, it was
revealed that there were gaps of up to 7 hours in his observation documentation [168].
Subsequently, TEWV claimed that changes had been made, for the purpose of increasing patient
safety on the ward [169]. Yet, mere months later (May 2007), 34-year-old Jason Walker died on
the same ward under extremely similar circumstances. Jason, who was admitted to Stephenson
following a suicide attempt, was also supposed to be on 10-minute observations. He died
after cutting his throat, with a blade he had somehow managed to extract from a disposable razor
[170]. According to news reports, his body may have laid unnoticed for hours as TEWV were
unable to produce evidence of any interactions between himself and the ward staff between the
hours of 9:30pm and 7:30am the next day, which was when his body was found. The reason
being that, despite his prescribed observation interval of 10 minutes, no documented observations
were made during that time frame, meaning he may have laid dying and/or dead for up to ten
hours. Moreover, members of the emergency team in attendance at the scene reported that
Jason’s body was cold to the touch, observing what they believed to be the stiffening of rigor
mortis [171]. After his death, three staff members were fired, including the ward manager. The
ensuing inquest identified a range of systemic failings on Stephenson ward, including [172]:
36
Inadequate risk assessment and management
Hazardous objects allowed on the ward
Poor or absent record keeping
Lack of observations
Observation charts falsified by staff
Medication charts completed incorrectly
Poor communication between staff regarding patient risk
Staff in breach of Trust procedures/policies
Neither of these men should have been allowed the access to hazardous objects/environments
or the time necessary to end their lives in such ways. In a similar vein, given their prescribed
observation level of only 10 minutes, there’s a reasonable likelihood that both men could have
survived, had those observations actually taken place when they were supposed to.
The deaths of Jason Walker and Jonathan Ferguson are disturbingly similar to the deaths of
Christie Harnett and Nadia Sharif at TEWV’s former CAMHS hospital, West Lane
14
. Christie and
Nadia, admitted to hospital for their own safety, ended their lives with items they had access to
on the ward, despite Christie being at high risk of harm, and despite Nadia being locked in
seclusion, where she should have been supervised by an appropriately qualified individual at all
times. Like Jonathan and Jason, neither Christie nor Nadia should have been able to die.
The systemic failings found on Stephenson ward in 2007 mirror the failings found by the CQC in
their 2019 inspection of West Lane hospital, which lead to the closure of the latter [173]. The litany
of failures at West Lane included:
Inadequate/absent risk assessment and management
Unsafe ward conditions:
hazardous objects allowed on the ward
environmental risks not assessed or managed
patient call alarms missing
Poor or absent record keeping
Lack of observations and poor observation practices
Unsafe storage and administration of medication
Poor communication between staff
Poor safety track records and ineffective procedures to learn from serious incidents
Staff in breach of Trust procedures/policies
The Trust ostensibly apologised for the catastrophic failures at West Lane hospital (covered
extensively in Section 3.5.1: West Lane Hospital), stating “we have put a lot of urgent actions in
to address some of the concerns” [174]. Despite the incredibly public scandal surrounding West
Lane, and the Trust’s repeated assurances that they were “absolutely devastated not only as an
organisation but on a personal level as well" [175], an unannounced 2021 inspection by the CQC
(in response to a serious incident) found that adult mental health wards across three Trust
14
See Section 3.5.1: West Lane Hospital
37
hospitals were grossly unsafe. Subsequently the Trust was issued with an enforcement notice to
rectify breaches of legal requirements [176]. The findings of this inspection included:
Inadequate risk assessment and management, including:
Ineffective framework to monitor, audit and oversee risk assessment processes
Lack of staff understanding of risk assessment process
Environmental risks present on wards
Poor documentation - patient records not up to date with risk information
Lack of staff understanding of patient observation processes
Poor communication between staff regarding patient risk
Poor safety track records and ineffective procedures to learn from serious incidents
Staff in breach of Trust procedures/policies
The CQC’s findings from 2021 mirror those found at West Lane in 2019, and those noted on
Stephenson Ward in 2007. As demonstrated by the last 15 years of recurring failures, it’s quite
evident that lessons are not being learnt by anyone at Tees, Esk and Wear Valleys Foundation
Trust, as inpatients continue to die entirely preventable and inexcusable deaths.
3.2.1.2 Inpatient Deaths Occurring off Hospital Property
On May 4th 2014, John Howe absconded from TEWV’s Park House in Middlesbrough, and was
found dead on a nearby beach the next day. John was detained at Park House, was not allowed
to leave unaccompanied, and was supposed to be on hourly observations. Nonetheless, he still
managed to leave the facility completely unnoticed. Staff falsified his observation records
three times, reporting that he was still present for several hours after CCTV recorded him leaving.
The inquest found “cumulative failureson the part of the Trust, who, again, claimed to have
learned from [the incident and had] implemented a range of measures including strengthening
our procedures and improving training for staff.” [177]
A year later, on May 29th 2015, Mr Andrew Fleming, an inpatient at TEWV’s Roseberry Park
Hospital, died at his family home on leave from the hospital, hours after his family pleaded to
have him sectioned” [178]. Andrew had made a number of incredibly serious suicide attempts
in the days leading up to the leave, which included “hurling himself” in front of oncoming traffic,
which resulted in him smashing through the windscreen of a truck; attempting to overdose on
painkillers; and attempting to electrocute himself in his hospital room. Both Andrew and his family
had expressed concerns about him being given home leave while he was so unwell. At the
inquest, Mrs Fleming said her husband was “highly agitated” on the day of his death, describing
how she had to centrally lock the car doors on the drive home, wherein he repeatedly attested
that “nobody would listen to him”. On arriving home, he immediately stabbed himself to death in
the family’s kitchen, in full view of his wife and child. At inquest, a jury found numerous failings
had contributed to Andrew’s death, including: insufficient communication between staff and
family; an overemphasis on leave and discharge; poor communication between staff; and that
it was inappropriate for Andrew to have been granted leave on the day he died [179-184]. In
38
response, TEWV reflected “it’s important that we learn from this distressing case and we have
already made a number of changes to the way we work.” [185]
Several months later, on 12th August 2015, Michael McMonigle died after leaving Lanchester
Road hospital. That day he had been visited by his parents, which included a trip to the hospital
cafe. At the end of the visit, Michael’s parents, who were not informed of his “significant” risk
of self-harm or that he was not supposed to be left unaccompanied when away from the ward,
said goodbye to their son, believing it was safe to leave him in the cafe on his own. This appears
to be the last time anyone saw Michael alive yet, between the hours of 14:30 and 22:00, his
absence went unnoticed by hospital staff [186]. When they eventually discovered him to be
missing, there was an inexplicably long delay of over an hour before staff contacted Michael’s
family, and an even longer delay of two hours before reporting him as a missing person. During
this two-hour period no search was undertaken of either the building or grounds; as such, it is
unclear what, if any, efforts staff made to find Michael in that time, or why the police were not
informed for two hours. Michael’s inquest found that his death was contributed to by neglect,
citing numerous Trust failures, including: the failure to update his risk assessment and care
plan; the failure to communicate risk levels to Michael’s family; the staff’s inadequate
understanding/ignorance of the Trust’s informal leave policy, including Michael’s consultant
psychiatrist, who was completely unaware the Trust even had such a policy; failure to raise
the alarm and perform adequate actions once recognising Michael was missing [187]. These
failings were deemed substantial enough to warrant the completion of a Regulation 28 Report
[188], as the coroner believed that, unless the Trust took action, future preventable deaths were
likely to occur. TEWV apologised for Michael’s death, admitting his death could clearly have been
avoided. Moreover, the Trust’s phrasing of their regret, remorse and commitment to change in
respect of Michael’s family, used exactly the same words as those offered to Andrew Fleming’s
only a month earlier: “it’s important that we learn from this distressing case and we have already
made a number of changes to the way we work” [189].
Irrespective of these three, entirely preventable deaths, occurring within a 15-month period under
disturbingly analogous circumstances, 6 months later Leo Crossling died under extremely similar
circumstances. On 5th February 2016 Leo was allowed to leave West Park hospital
unaccompanied. This was despite his psychiatrist’s expressions of serious concern for Leo’s
safety only the day before, to the effect that he was “high risk” and should undergo a risk
assessment before any leave was granted. The subsequent inquest found numerous failings in
Leo’s care, stating his death was contributed to by “gross neglect [190].
After Leo’s inquest, TEWV confirmed that an external independent review of all serious incidents
relating to patients who died while on leave had been commissioned, and was due to be finalised
in 2017 [191]. Following an FOI request, from which the authors obtained a heavily redacted
15
report of the review’s findings, it became apparent that the review only examined serious incidents
occurring in the months between February 2015 and October 2016. In spite of this relatively short
time period, the review unearthed 15 serious untoward incidents involving the deaths of 15
15
The report’s “Methodology” section clearly states that all patient information was anonymised, and that “No additional
crosschecking or triangulation of the incident reports occurred, i.e. clinical records or other patient specific information was not
accessed.” As such, the authors are utterly mystified as to why TEWV felt it necessary to redact a third of its content.
39
inpatients on leave from the hospital. Of these 15 deaths, 12 were suicides
16
. A number of themes
became apparent, including missed opportunities for intervention; inconsistent approaches
to risk; significant similarities with the deaths; and issues with the serious untoward incident
review process [192].
The findings of this external, independent review were made available to TEWV in 2017. Yet, two
years later, in May 2019, Peter Brown left Cross Lane Hospital in Scarborough for a walk, and
never returned. After two years of searching by his family and the local community, in 2021 his
body was finally discovered by the side of a railway line. While her husband was missing, Peter’s
wife, Natalie, stated they had both been distressed by the standard of care at Cross Lane hospital,
noting Peter had waited an entire week on the ward before being assessed by a doctor [193].
Although the investigation is yet to conclude, the assistant coroner announced Peter’s body was
“found in circumstances that suggest he had taken his own life” [194].
Several months later, in September 2019, Pamela Brown, who was detained under the Mental
Health Act at Roseberry Park Hospital, died after leaving the hospital grounds. Pamela had been
allowed 10 minutes unescorted leave from the ward but did not return. Despite staff noticing she
had not returned within 20 minutes, they failed to contact the police for 2 hours. The inquest heard
of a catalogue of failures in Pamela’s care, which at the time had prompted her daughter to file
safeguarding concerns. Pamela’s risk assessment was also found to be inadequate [195]. In
response, TEWV stated, we will continue to make improvements to our services, particularly
around training, communication, and the way we collaborate with patients, families and carers
when assessing clinical risk.” [196].
3.2.1.3 Patient Deaths in the Community
On 6th June 2011, 41-year-old Mark Janney died by suicide, after services denied him care on
three separate occasions, following three attempts to end his life [197]. He first sought help from
the Emergency Department at Scarborough General Hospital, after attempting suicide on 21st
May 2011. There, he was assessed by the local crisis team, who decided there was no evidence
of suicidal intent. Yet, following a concerned call from his partner the very next day, the police
had to force their way into Mark’s flat, where they discovered him actively attempting to end his
life. Though the police made contact with mental health services, Mark was refused an
assessment. The police then tried the local minor injuries unit, which also refused to assess
Mark. Mark attempted suicide again only six days later, and was, again, discharged from
Scarborough General Hospital without assessment. He died by suicide a week later, with TEWV
admitting liability and apologising for not providing appropriate intervention [198].
On 30th September 2013, 46-year-old Jeffrey Gash, died under very similar circumstances. Prior
to his death, Jeffrey had made numerous attempts to seek help from TEWV’s crisis services [199].
The first contact came on the 29th of August, after his GP referred him to the crisis team, and he
was subsequently seen by a psychiatrist. On the 27th of September, Jeffrey’s wife telephoned his
16
While the review confirmed 12 of the 15 incidents were deaths by suicide specifically, the Trust response to the FOI request
confirmed all 15 serious incidents were patient deaths.
40
GP out of concern for his welfare. In particular, she revealed that he was distressed and that he
was hearing voices. Subsequently, Jeffrey’s GP contacted the crisis team again, who, despite
receiving this new information regarding a change in Jeffrey’s risk profile, refused to visit him at
home. The following day Jeffrey telephoned the crisis team himself, whereupon he informed the
crisis nurse on duty that he felt worse, and had spoken to the Samaritans. The crisis nurse,
misguidedly believing Jeffrey’s seeking of assistance (from the Samaritans) to be a sign of
improvement, decided not to visit and not to escalate his case. Jeffrey died by suicide only two
days later. His suicide note said: “I went to see the doctors at West Park Hospital I was hurting
every day but they weren’t interested.” At inquest, a profusion of individual and systemic
failures were uncovered, including the failure to properly assess and manage Jeffrey’s risk;
failure to organise a face to face assessment with Jeffrey; lack of staff training regarding telephone
risk assessments; inadequate record keeping; and a lack of training and policy regarding
declining home visits. These failings were deemed substantial enough to necessitate a Regulation
28 Report [200].
Nonetheless, in August 2016, 25-year-old Luke Gaul ended his life under similar circumstances,
that is, after both he and his GP had repeatedly tried to seek help from TEWV [201]. Upon telling
his GP he was having suicidal thoughts he was immediately referred to TEWV, who placed him
on a waiting list for months. Deeming this to be inadequate, his GP attempted to escalate this
further with the Trust, seemingly to no avail. In the last weeks of his life, Luke poignantly
articulated the personal repercussions of the Trust’s apathy towards his existence, stating: “I
cannot put into words how incredibly worthless and inconsequential you have made me feel. It’s
hard, reaching out for treatment, but it’s even harder to have doors constantly slammed in your
face and being passed around like you don’t matter.” Though the ensuing inquest (inexplicably)
found no failures, during the subsequent civil case the Trust admitted Luke’s care had fallen
below the standard expected.
On 9th December 2016, only months later, 54-year-old Anthony Pratt died by suicide, despite
making numerous attempts to engage with TEWV, including “begging” to be sectioned [202]. After
hearing voices telling him to kill himself, in the weeks before his death, Anthony telephoned the
Trust every day (sometimes several times) for up to an hour at a time. According to his daughter,
one of the people Anthony spoke to told him they couldn’t help him “until he picked himself
up a bit”. In spite of his worrying symptoms, his distress, and his innumerable efforts to seek
help, no face to face appointment was ever offered, and he was never properly assessed. At
inquest, numerous failings were exposed, with TEWV admitting to numerous errors, stating:
“Since this sad incident we have reviewed the way we work and have made changes” [203].
Four months later, in April 2017, 38-year-old Peter McCluskey died by suicide hours after a TEWV
crisis team decided he did not warrant hospital treatment. At inquest the Trust professed to
have made a number of pertinent changes to their practice, stating there had been a “missed
opportunity” to provide Peter the necessary support. Such “changes” ostensibly included daily
engagement with patients within crisis services and, notably, fuller engagement with the patient’s
family [204]. Yet, only three months later, in July 2017, following the suicide of 52-year-old Tristan
Berthoud, Tristan’s family stated that the Trust had failed to listen to them, and had failed to
involve them in the creation of an appropriate care plan [205]. Once again TEWV avowed that,
41
following a serious incident review, they had strengthened arrangements for involving families in
the care process.
However, just two months later, in September 2017, 30-year-old Christopher Stewart died by
suicide after being discharged from Roseberry Park hospital, where he had been involuntarily
detained under the Mental Health Act 1983 (MHA). Christopher’s family reported they were not
invited to the discharge meeting, nor were they even made aware that he was being
discharged. No formal discharge plan was ever put in place and, when asked of their rationale
for his discharge, staff explained: “he had the “capacity” to make the decision [to leave] and could
not be detained there against his will”
17
[206]. The inquest revealed a number of failings in
Christopher's care, to which the coroner simply concluded: “I have been assured by the trust that
steps have been taken and now those issues will no longer be present in the care of other
patients.” [207]
Another two months later, in November 2017, 38-year-old Rachael Redding died shortly after it
had been recommended that she go into hospital. At inquest, her death was recorded as
misadventure. In giving evidence, Rachael’s mother revealed that, although her daughter had
initially received support from TEWV (including a community psychiatric nurse), Rachael was later
discharged after declining CBT, on the basis that she wasn’t “engaging” [208]. This was despite
a long-standing history of bipolar disorder. In July 2018, 21-year-old Isaac Eastwood, who also
had a diagnosis of bipolar disorder, died by suicide following an episode of acute crisis. Under
circumstances similar to Rachael’s, three days before Isaac died his care coordinator
recommended that he be admitted to hospital [209]. Moreover, his family had requested he
be hospitalised three times in the weeks leading up to his death [210]. Yet, TEWV’s crisis team
did not agree with Isaac’s care coordinator, declining to admit him, despite having not conducted
a face-to-face review. Isaac died two days later. The inquest heard of numerous failures in
Isaac’s care, including a lack of appropriate consideration and acknowledgement of the
nature, degree and severity of the risks that Isaac presented”. According to TEWV’s serious
incident report, both the root causes of Isaac’s death and the ensuing areas of improvement were
highlighted and “positively addressed” [211].
Just months later, 22-year-old Kaylee Chambers died by misadventure on 13th November 2018,
after services “left [her] in a state of torture” [212]. Kaylee, who was hospitalised as a child
within TEWV’s West Lane CAMHS facilities, had made a number of suicide attempts and was
struggling with issues relating to trauma and bipolar disorder. In the weeks prior to her death, she
was experiencing distressing hallucinations, and had been acting out of character. At inquest, it
transpired that Kaylee had been unable to contact her community psychiatric nurse, despite
making numerous attempts over a 12-week period. Moreover, issues with the phone lines at
Parkside Mental Health Centre, Kaylee had also struggled to get through when in need of support.
Just days after Kaylee’s death, on the 19th November, 19-year-old Callum Riley died after he was
17
It’s possible that this error arises from a conflation of the Mental Health Act 1983 with the Mental Capacity Act 2005 (hospital
detention under the latter is only lawful when the individual in question lacks the capacity to make the decision for themselves, at the
time it needs to be made). Nonetheless, consultant psychiatrists, more than any other mental health professional, have an explicit
statutory duty to “have regard to” the codes of practice for both statutes. In other words, there is absolutely no legitimate excuse for
making this mistake, and it seems Christopher was discharged for wholly unlawful reasons.
42
turned away by TEWV’s Lanchester Road Hospital, after his father had “begged” staff to
section him [213]. Like Kaylee, Callum also had a history of suicide attempts precipitated by
serious mental health problems. Though Callum’s GP was able to recognise his extremely high
risk of suicide, services, it seems, were not. More specifically, TEWV were unwilling to provide
more intensive mental health support until Callum “[sorted] his drug problem out”. At Callum’s
inquest, the coroner expressed concern about the information unearthed by TEWV’s subsequent
serious incident review, commenting that, despite Callum being under the care of numerous
TEWV teams, there was no overall or comprehensive assessment of his needs. Less than a
month later, on the 15th of December, 23-year-old Viktor Scott-Brown died by suicide, having
been “let down on many levels” [214]. At inquest, it became apparent that the trust had failed to
undertake any clinical assessment of Viktor’s risk, nor had they written him a care plan.
Furthermore, Viktor’s family revealed that the Trust’s serious incident review exhibited
inaccuracies they believed were “designed to downplay the trust’s involvement in Viktor’s death.”
After the inquest, the Trust stated: “[we have] taken action to address the findings from [the
serious incident review]. We will now take some time to look at the coroner’s recommendations
and make sure we embed the learning from these as well as those from our own review.” [215]
Nevertheless, four months later in the April of 2019 27-year-old Jennifer Brown died by
misadventure while under the care of TEWV’s adult community services [216]. At inquest, TEWV
admitted that, despite Jennifer’s diagnosis of bipolar disorder, and despite her having been in the
Trust’s care for several years, astoundingly, Jennifer also had no written care plan. Moreover,
her clinical team were completely unaware of her two previous suicide attempts, as
messages left by Emergency Department staff had not been picked up. Her clinical notes were
also found to contain no next of kin contact details, despite her family’s active participation in
her life, and despite TEWV’s historical assurances regarding their communication with patients’
families. At inquest, the Trust admitted opportunities to help Jennifer had been missed, while her
family questioned “how many times did she need to ask for help?” TEWV, yet again,
announced that they had taken action to address the findings of their review.
16-year-old Jesse Carly Walker died on the 23rd of January 2020, whilst under the care of
TEWV’s CAMHS clinicians. The evening before, Jesse had expressed suicidal thoughts whilst
talking to a Childline operator through their anonymous online live chat service. Following this
exchange, Childline were so concerned for Jesse’s safety, they enlisted the National Crime
Agency to help trace her location from her IP address. In the early hours of the next day the local
police visited her at home to conduct a welfare check and, finding Jesse asleep in her bedroom,
left after speaking with her parents. The officer also forwarded the transcript of Jesse’s
conversation with Childline to Jesse’s mental health team [217]. Notwithstanding, Jesse’s
community nurse did not contact her parents or inform them of her suicide plan. Later that
morning Jesse’s mother contacted the nurse herself. She asked for an appointment that day,
stating she was “desperate for help”, but was told the nurse had appointments all morning, and
was on annual leave in the afternoon. Jesse died later that same day. The inquest heard that a
review of Jesse’s care highlighted the Trust’s failure in refusing to see Jesse on the day she died,
and their failure to notify her parents of her suicide plan. TEWV subsequently announced that
steps had been taken to improve services, and that Jesse’s nurse had “changed her practice”
[218].
43
In October 2020, 23-year-old Emily Miller was admitted to Foss Park Hospital in York after
attempting suicide. Emily was experiencing distressing symptoms of psychosis, which were
dismissed as “quasi-psychotic” due to her diagnosis of EUPD. Emily had been in hospital on a
number of occasions and was frequently discharged very quickly, despite remaining high risk.
Although Emily was deeply distressed and suicidal, believing she was responsible for coronavirus,
her final admission only lasted three days before she was discharged against her will. Emily
ended her life 30 minutes later, after jumping into the River Ouse. At inquest, TEWV staff
commented that despite Emily frequently talking about suicide and stating suicidal plans, they
didn’t believe she was actually at risk and were surprised by her death [219, 220]. In April
2021, 23-year-old Dari-Anne Sawyer ended her life at her home in Thornaby. Dari-Anne had seen
TEWV staff the day she died, where she informed them that she had taken an overdose. The staff
told Dari-Anne she should go to hospital, and then left her at home by herself. No concerns were
raised by the staff regarding her safety, as similar to Emily Miller, there seemed to be a lack of
belief that she was at risk. Dari-Anne died later that day [221].
The aforementioned cases are only the tip of the Trust’s proverbial iceberg, with regard to patient
deaths that could and should have been readily prevented, were it not for TEWV’s shamelessly
flagrant disregard for patients’ lives. Such is glaringly evident from this 15-year pattern of: patient
failed - patient dies - lessons learned; patient failed, again - patient dies, again - lessons learned,
again; patient failed, yet again - patient dies, yet again - lessons learned, yet again; ad infinitum.
Again, and again, and again, and in spite of countless promises to the contrary, from the time
TEWV was founded to the present day, the same, lethal, indefensible mistakes are propagated
and repeated across the entire Trust. It appears that the Trust’s promises that they are
“addressing the concerns”; “learning from the incidents”; strengthening their procedures”;
“making a number of changes”; “reviewing the way they work”; “taking steps”; “positively
addressing areas of improvement”; “taking action to address the findings”; “embedding the
learning”; “changing practices”; and “making significant changes”, are as disingenuous as they
are profuse. The authors strongly support calls for a public inquiry, in which the following question
must be answered: why and how has this been allowed to continue for so long?
“I’m hearing repeat stories, the failure to risk assess [patients] properly, the poor case
management - failure to listen to the concerns of families. Yes mental health is difficult, it
is challenging but these deaths that I have seen should not have happened, they were
simple failings.”
- Alistair Smith, Solicitor, Watson Woodhouse [222] (bold ours)
I mean these are alarming figures. One death is one death too many but to see a pattern
of death and many of these deaths raise concerns about failings. It really is an extreme
matter of public concern and really does warrant a proper inquiry into the trust itself.
- Deborah Coles, Executive Director, INQUEST [223] (bold ours)
44
3.3 There is No Evidence
Most people recover from BPD in the long term (Paris 2008 and Zweig-Frank 2001) However,
recovery requires that develop skills [sic] and self efficacy from facing and overcoming crises in
their lives. When responsibility is assumed by others this also removes the opportunities that
support recovery. Many of the familiar interventions for reducing short term risk of suicide and
severe self harm (e.g. hospitalisation, enhanced observations, and increased frequency of
community contact) can have negative short or long term side effects for people with BPD+
18
. For
instance, enhanced observations can sometimes reduce a person’s responsibility for their own
wellbeing and create conditions for reckless behaviour. Or hospitalisation can convey to a person
that professionals feel they are incapable of looking after themselves, thus reducing self efficacy.
The Trust recognises that optimal care for people with a diagnosis of BPD+ often means offering
the patient care plans that “play the long game”, that strategically hold back from short term risk
19
reduction (or the appearance of short term risk
20
reduction) in order to achieve long term gains or
reduce long term harms. This is therapeutic risk taking
21
.
When reading the Protocol’s statements regarding the purportedly “harmful” effects of
hospitalisation, frequent community contact, enhanced observations etc, it’s important to
appreciate that absolutely none of these claims are backed by empirical evidence or national
clinical guidelines. Indeed, the entire Protocol is predicated upon a specious foundation of
personal opinion and anecdotal evidence
22
.
Currently, at the time of writing, there is no adequate randomised controlled trial (RCT) evidence
supporting any specific crisis intervention for BPD-labelled patients [224,225]. NICE guidelines
recommend that, when a BPD-labelled patient presents during a crisis, services respond in a
calm, empathetic manner, and actively involve the patient in exploring options for crisis resolution.
Interventions could include: follow up contact, or immediate daily contact in the community;
cautious short-term use of medication; contact with a crisis resolution and home treatment team;
arranging outpatient care or treatment; and admission to a psychiatric inpatient unit [226].
Contrary to the Protocol’s repeated statements regarding harm, the empirical evidence available
indicates hospitalisation is not, in fact, harmful to BPD-labelled patients and does not contribute
to a deterioration in health [227-229]. The NICE guidelines, in conjunction with various academics
in this field, propose that such assumptions derive entirely from the opinions of individual
clinicians, in lieu of any legitimate scientific enquiry [230-232]. Indeed, the empirical evidence
available actually reveals that, currently, there is no known optimal crisis treatment in this patient
18
In version 2 the sentence “can have negative short or long term side effects for people with BPD+” was changed to “can bring
about unintended harms for people with BPD+.
19
In version 2 the word “risk” is changed to “harm
20
In version 2 the word “risk” is changed to “harm
21
In version 2 the sentence “This is therapeutic risk taking” was changed to “This is a comprehensive approach to harm reduction.
22
In medical research, types of evidence (e.g. randomised controlled trials (RCT), cohort studies, case-control etc) can be sorted
into hierarchies according to the quality and reliability (high, medium or low) of each source. ‘Expert opinion’ is frequently excluded
from even the lowest levels of evidence included in such hierarchies and, when it is included, it rather conspicuously occupies the
lowest position. See: Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plast
Reconstr Surg. 2011;128(1):305-310.
45
population [233]. Moreover, interventions the Protocol confidently rejects as “harmful” (including
home treatment, hospitalisation (including periods longer than a few days), day hospitals and
intensive therapeutic interventions) have, in fact, been proven beneficial, or are strongly
suggested to be so [234-238].
Another factor to consider, when reading this Protocol, is that all “evidence” provided refers only
to patients labelled with BPD. Yet, as discussed earlier, the Protocol is actually aimed at a
substantially wider range of diagnoses, which, in addition to BPD, could include a further 53
discrete diagnostic groups. Explicitly claiming that:
- ‘increased frequency of community contact [...] can have negative short or long term side
effects’ (pg. 2, V1)
- ‘the sort of care that looks after the person in a protective way [...] may increase the risk
of suicidal or self harm behaviour’ (pg. 6, V1&2)
- ‘hospitalisation [...] can have negative short or long term side effects’ (pg. 2, V1)
- ‘caring interventions that are at the core of mental health work, and provided for many
other patients, might be harmful for a particular person with a diagnosis of BPD+’ (pg. 6,
V1&2)
- ‘Offering a lot of intervention, or long interventions, or specialist interventions, can
convey to the person a sense that they “really are very disturbed”’ (pg. 7, V2)
- ‘The interventions that mental health services typically offer patients, and are socially
expected to offer, at times of crisis often make things worse for people with BPD+’ (pg. 6,
V1; pg. 7, V2)
not only contradicts the most current evidence regarding crisis management for BPD-labelled
patients, but also completely ignores all good practice guidelines, and evidenced based treatment
interventions, for every other diagnosis subsumed by “BPD+”. Such is an egregious violation of
the Trust’s statutory duty to provide safe, regulated, clinically appropriate, individualised care and
treatment to every one of its patients.
3.4 Positive Risk-Taking: An Introduction
The Trust supports well considered, well documented therapeutic risk taking according to the
principles of this protocol, and will continue to support such risk taking even when tragic events
occur
23
.
“Positive” risk-taking (aka, “therapeutic” risk-taking), in its true form, is about patient
empowerment through the facilitation of autonomy and choice [239-242]. The theory of positive
risk-taking is that when people choose to take on more responsibility for their own safety, while
they may be at an increased risk of harm, the action of taking back control of their life is an
23
In version 2 the sentence “The Trust supports well considered, well documented therapeutic risk taking according to the
principles of this protocol, and will continue to support such risk taking even when tragic events occur “ was changed to “The Trust
supports teams taking a well considered, well documented comprehensive approach to harm reduction in line with the principles of
this protocol, and will continue to support this even when tragic events occur.”
46
empowering one which may support recovery and/or lead to an increased quality of life. For
example, supported living staff may be concerned that a client with a learning disability may be at
risk of getting lost if they go out for walks alone. Thus, to eliminate this risk, staff always
accompany the client when they go out for walks. Yet, this fails to consider the desire of the client
to go out by themselves, reducing their levels of independence, and negatively impacting their
quality of life. A positive risk-taking approach may support this individual in their desire to go out
alone, with both the staff and the individual fully aware that the increased risk of harm is balanced
against improved quality of life [243].
As much as the preceding example might appear to bear clinical merit, in truth, precious little is
known about the real value, if any, of utilising positive risk-taking approaches within clinical
practice [244-246]. Indeed, this present state of affairs has already been noted by others, for
example:
“The research available on the use of positive risk-taking in clinical practice is surprisingly
limited” [...] “There is a gap in the research on how positive risk-taking affects service users
and whether it does promote recovery. Policy makers cannot be expected to change their
views on risk-taking if there is no evidence to support its effect on recovery.”
- Reddington, G. The case for positive risk-taking to promote recovery [247]. Pg
29-32
“[..] positive risk-taking approaches do not yet appear to have been formally evaluated in
terms of outcomes for, and experiences of, those receiving services […] [T]he “evidence
base” for positive risk taking is not clear cut.”
- Blood I, Wardle S. Positive risk and shared decision-making [248]. Pg.8
“The promotion of positive risk taking has been proposed as an essential capacity for
health and social care staff, but little is known of the dimensions and value of this
approach.”
- Robertson J, Collinson C. Positive risk taking: Whose risk is it? [249] Pg. 147
Of even greater concern, is the total dearth of evidence regarding the safety and efficacy of such
approaches when employed during acute suicidal crises. In spite of such, the authors’ main
quarrel is not with “positive” risk-taking per se which, despite aforementioned concerns, may have
clinical value when implemented with care, and with the patient’s full involvement. Rather, the
authors’ primary concern relates to the deceptive, unlawful and reckless version of such utilised
47
by TEWV. To be clear, the clinical risk(s) in question here, are borne entirely by the patient
24
, that
is, where such risk is not properly managed, it is the patient who suffers the material
consequences, not the staff. For example, where a patient is not protected from an overt risk of
suicide, it is the patient who dies, not the nurse/doctor/etc who failed to take them seriously
25
. In
short, these risks are not “taken” by staff, they are taken by patients. As such, positive risk-taking
is only clinically legitimate when employed with the full knowledge and informed consent of the
patient. To do otherwise is not only a clear violation of the patient’s personal sovereignty, but
(despite the Protocol’s protestations), is an open invitation to neglect, abuse, human rights
violations and, ultimately, preventable patient deaths resulting from such.
Tragically, this particular manner of preventable patient death is not merely a possibility in the
abstract. Indeed, it is very much a reality for the family of Valeria Muñoz Biggs, who died following
jumping into the path of a train in September 2019 [250]. Valeria had a significant history of
affective disorder, beginning at the age of 18, for which she had previously been successfully
treated in her home country of Chile. She also had a very strong family history of bipolar disorder.
In 2019, while living in the UK, Valeria experienced an exacerbation of her symptoms. She sought
urgent psychiatric help for her feelings of active suicidality on 12th September 2019, dying by
suicide only 8 days later on 20th September, aged 31. At inquest, HM Senior Coroner, Dr. Fiona
Wilcox, found the Trust responsible for Valeria’s psychiatric treatment, West London NHS Trust,
had actually contributed to Valeria’s avoidable death by failing to take her suicidality seriously.
Most significantly, Dr. Wilcox noted the Trust’s ‘concerning culture of positive risk taking [sic] in
relation to suicidality’ as a contributory factor.
From the findings at her inquest, it seems the Trust were taking risks with Valeria’s life without
her consent or knowledge from the moment she approached them in crisis
26
, on 12th September.
When they failed to take her suicidality seriously, she attended A&E, where liaison psychiatry
services found her unwell enough to discuss admission to hospital. However, she was ultimately
referred to the Trust’s community crisis home treatment team (henceforth: “crisis team”),
supposedly with a low threshold for admission if her risk increased or her family weren’t coping.
The crisis team were due to visit Valeria at home the next day (13th September) but failed to show
up, despite receiving a report from the police that same day, to the effect that Valeria had been
found wandering at a local train station expressing overtly suicidal thoughts to members of the
public, one of whom called emergency services. The crisis team eventually visited her home two
days later on 15th September, by which time Valeria had left home with suicidal intent on at least
four occasions. At this point Valeria’s family were, quite understandably, very frightened for her
safety. They expressed their grave and pressing concerns to the crisis team regarding her
imminent risk of suicide, having been unable to keep her safe at home. These concerns went
unheeded and largely undocumented. The crisis team failed to ever undertake a proper
assessment of Valeria’s risk, failed to alter her treatment plan accordingly and failed to reconsider
the necessity of hospital admission. Rather, they inexplicably ignored overt signs of Valeria’s
24
And, in a different way, by their relatives/family
25
This is not to say staff suffer no ill effects from such e.g. guilt, grief, professional/legal consequences, just that these are the
consequences of related risks (e.g. the risk of not adequately mitigating risk), not of the patient’s risk of death by suicide.
26
Please note, this supposition is based on the findings as summarised in the Regulation 28 report. The full inquest report is not
accessible.
48
deteriorating condition; her consistently active suicidality; the high-risk manifestations of such (i.e.
making repeated visits to train stations) her psychiatric history; her family history of bipolar
disorder; concerns from numerous other professional sources (police, liaison psychiatry etc) and,
particularly, her family’s struggle to manage her safety at home. Essentially, it seems that, aside
from (eventually) showing up, the Trust did absolutely nothing for Valeria of material clinical value.
Indeed, at inquest, Dr. Wilcox found this debacle of incompetence to be ‘a gross failure on the
part of the Trust’, concluding that, had Valeria been adequately assessed and admitted to
hospital, she would not have died.
These findings were of sufficient concern for Dr. Wilcox to complete a Regulation 28: Report to
Prevent Future Deaths, in addition to her inquest report. The call for such is only engaged where
‘anything revealed by the investigation gives rise to a concern that circumstances creating a risk
of other deaths will occur, or will continue to exist, in the future’
27
. In such cases, the coroner has
a statutory duty to complete a Regulation 28 form detailing their specific concerns, which is sent
to the person/organisation of note
28
(i.e. West London NHS Trust in this case) and the Office of
the Chief Coroner. In her summary of the evidence presented at inquest, Dr. Wilcox again noted
the Trust’s ‘concerning culture of positive risk taking [sic] in relation to suicidality’ as part of a wider
picture of neglect, wherein staff consistently ignored or underestimated every aspect of Valeria’s
presentation suggestive of a high risk of suicidality. This “risk-ignoring” approach to the clinical
management of suicidality, took place against a background of abject lack of support or
engagement with either Valeria or her family. As noted by Dr. Wilcox:
‘There was a repeated theme of lack engagement [sic] with those attempting to care for
Valeria at home; a lack of support for her carers; not recording concerns raised by carers;
[...]
Valeria was not properly offered admission to hospital, but rather pushed toward care in
the community and this decision was never re-visited during the episode of care despite
the difficulties in managing her safety at home; her lack of improvement and even apparent
worsening; her strong family history of bipolar affective disorder and the strong possibility
that this was her underlying diagnosis; and her active risk of suicidality which was overt to
her family [...]
[...]
Lack of proper assessment of suicidality for example: seeming to ignore her actions, and
concerns passed by her brother who was caring for her and over reliance upon no active
suicidality being expressed when directly asked. Even when she was at times so unwell
that she would not talk or was incoherent there was no reassessment of risk
27
Schedule 7, subsection 1(b), The other aspects of this statutory duty are found within the rest of Schedule 7 of the Coroners and
Justice Act 2009. Also, see paragraph 10 of Guidance No.5 Reports to Prevent Future Deaths, Office of the Chief Coroner,
28
More specifically, it’s the person/organisation the coroner believes has the power to act on such concerns. This
person/organisation has a duty to respond within 56 days from the date of the Regulation 28 report.
49
The most pertinent section of a Regulation 28 report is that in which the coroner records their
concerns arising from the case, with specific regard to the prevention of future deaths
29
. A total of
8 such concerns were formally recorded in Valeria’s case, the very first being ‘[t]hat the Trust has
a culture of risk taking in relation to suicidality’. This is now the third occasion on which Dr. Wilcox
raises explicit concerns regarding the possibility of future deaths arising in connection with the
Trust’s use of positive risk-taking practices in relation to suicidality. It is also the third occasion on
which the practice is noted as being a factor in Valeria’s entirely preventable death. Most of the
concerns that follow can be summed up as thus: both Trust and staff provided such woefully
inadequate care, demonstrating manifest incompetence in numerous aspects of such, that a
senior coroner had to tell them how to do their job(s) in infuriatingly basic terms, solely for the
purpose of preventing future deaths from such
30
. Addressing her final concern, Dr. Wilcox notes:
‘[t]hat this case seriously calls into question the operational ethos of the care in the community
approach in West London’.
The preceding was merely a concise overview of this case, as such, many relevant aspects of
the Regulation 28 report were omitted. Upon reading the report in its entirety, it seems rather
apparent that the ‘operational ethos’ of concern is remarkably similar to that witnessed by patients
at TEWV. Regardless of what manner of care the Protocol claims to promote in theory
31
, its reality
would seem to entail a standard of care even lower than that reported by Dr. Wilcox. While one
dismissive-sounding comment from a staff member (‘“you are so pretty why would you want to kill
yourself”’) was noted as innapropriate, the staff member responsible is noted as having positive
intent (‘a clumsy attempt to cheer [Valeria] up’). It appears there was no evidence of staff
delivering callously dismissive moralisms
32
in response to patient suicidality, nor was there
evidence of staff goading fragile patients into escalating their attempts in order to be “taken
seriously”
33
. Nonetheless, the “care” Valeria received in the days before her death bears similar
hallmarks to that reported by patients of TEWV, that is:
A lack of engagement with/support for the patient.
A lack of engagement with/support for the patient’s family.
A lack of proper suicide risk assessment.
Failure to reassess/revisit decisions regarding risk and care provision in response
to patient deterioration.
Completely ignoring/not noticing very overt indications of escalating suicide risk,
i.e.:
ignoring the patient’s overtly suicidal behaviour re: visiting
train/underground stations;
29
“Box 5” or “the coroners concerns” is the essence of a Regulation 28 report. The concerns recorded need not relate to the death
in question; any concerns arising re the prevention of future deaths may be noted.
30
Perhaps this is why Dr. Wilcox felt it necessary to formally record her ‘concerns about the credibility of some of the evidence
given by the Trust witnesses, and the ability of the Trust to reflect upon and learn lessons from this death.’ earlier on in the report.
31
Which, to be clear, is still unlawful and negligent
32
E.g. ‘You have capacity’; ‘you are responsible’; ‘you need to learn some responsibility’; ‘you’re not genuine, you’re just being
manipulative’ etc
33
I.e. ‘If you really wanted to die you would have…....taken more pills, isolated yourself, not called us etc’
50
ignoring the patient’s clear deterioration into episodes of complete silence
or incoherence;
failure to even bother documenting the frequently-expressed concerns of
the family;
failure to ask the patient about active suicidal feelings;
failure to note relevant historical details e.g. a family history of bipolar
disorder.
Failure to consider hospital admission when it was clearly appropriate.
Forcing the patient’s family to formally “manage” their beloved’s risk of suicide, as
a means of mitigating the Trust’s neglectful approach.
Failure to follow the relevant guidelines.
Failure to meet the relevant statutory obligations.
Failure to keep proper documentation.
The credibility and honesty of the Trust and its staff called into question
Though the preceding points relate exclusively to the Valeria Muñoz Biggs case, each is just as
easily entailed, either by inclusion or omission, by the principles within the Protocol
34
. Moreover,
the one and only “culture of risk management” relentlessly pushed by this document, that is,
“therapeutic risk-taking”, is nothing but a slightly nicer-sounding recapitulation of “positive risk-
taking”. This is the same ‘culture of positive risk taking in relation to suicidality’ the coroner noted
as a significant contributory factor in the preventable suicide of Valeria Muñoz Biggs.
The Protocol offers zero empirical evidence to legitimise TEWV’s reckless use of positive risk-
taking in patients labelled BPD+. Rather, it blindly asserts ad nauseum, that the Trust’s exclusive
reliance on this entirely untested, unevidenced, non-risk assessed, thus, possibly lethally unsafe
approach to suicide risk management is ‘not a negligent lack of attention to potential risks’ (pg. 4,
V1&V2). Indeed, TEWV has such immense confidence in their baseless assertions, the Protocol
further pronounces that they will ‘continue to support such risk taking even where tragic events
occur’. In other words, no quantity of patient deaths occurring under ‘such risk taking’ will be
sufficient to deter them from using it on subsequent patients.
3.4.1 BPD-Specific Positive Risk-Taking
As positive risk-taking often involves reduced patient-staff interaction, and/or the reduction of
active support, there is always the risk of it being abused where the patient population is viewed
extremely negatively by staff [251]. As previously explained, BPD is deeply stigmatised within
mental health services. Numerous studies demonstrate that many mental health professionals
prefer to avoid BPD-labeled patients, whom they perceive to be “manipulative”, “attention-
seeking”, less unwell than other patients, more responsible for their behaviour and, overall, not
deserving of NHS resources [252-257]. These professionals may also be blinkered by the strength
34
I.e. while not all of such are explicitly provided for in the Protocol’s text, it’s glaring omissions regarding practical implementation
of the Protocol’s principles, risk assessment, consent, capacity to consent, duty of care, duty of candour, human rights etc, are a
fertile breeding ground for neglect and negligence.
51
and nature of their personal feelings concerning BPD-associated behaviours they find difficult,
distressing and hard to treat (i.e. self-harm and suicidality) [258-261], and by their extreme
discomfort with the histories common to such patients (i.e. past history of trauma, such as child
sexual abuse) [262-265].
When you combine these factors with a clinical intervention warranting reduced staff-patient
interactions for the purposes of encouraging patients to take responsibility for themselves, you
are presented with a uniquely dangerous situation, whereby this intervention could be abused
to serve the interests of a staff wishing to avoid caring for a patient group that challenges their
professional identity, and whom they (wrongfully) perceive as responsible for their distress and
less deserving of care.
It is certainly not unheard of for clinicians to carry out interventions or treatments that serve their
interests, rather than the interests of their patients. In a study of mental health professionals in
New Zealand, 85% of those questioned admitted that, in the past year, they had taken a treatment
approach with BPD-labelled patients which they did not consider clinically indicated or
appropriate, but that was in their own interests [266]. 18% of those questioned admitted that this
had occurred more than 50 times in the past year.
The experiences of the many TEWV survivors contributing to this report, have led the authors to
conclude that patients labelled with BPD, or perceived to fit the BPD “caricature”, commonly
experience clinically inappropriate and neglectful use of positive risk-taking at this Trust.
Experiences commonly described by TEWV survivors (including child and adult patients, families,
and carers):
- Patients having no knowledge of this intervention being used on them
- Patients refusing, or not asked for, their consent to positive risk-taking, but treated with it
regardless
- Patients not offered any alternative forms of intervention
- Patients and carers not being involved in any form of risk assessment or crisis/care plan
- Patients not having a risk assessment or crisis/care plan
- Patients not informed of a risk assessment or crisis/care plan they later find to exist
- Patients and carers confused about why contact was being reduced during a crisis
- Patients deliberately left to self-harm in hospital for extended periods of time
- Patients and carers told the patient needs to take complete responsibility for themselves
while in acute suicidal crisis
- Patients and carers told the patient allegedly “has capacity” and therefore it’s their choice
to kill themselves
- Patients and carers told the patient allegedly “has capacity”, despite the patient never
having their capacity assessed
- Patients told, after they attempt suicide, that they are “attention-seeking” so shouldn’t
receive care
- Patients and carers told personality disorders are just “behavioural” and, as such, the
patient is taking up space in hospital
52
- Patients and carers told it's not the Trusts responsibility to keep their hospital inpatients
safe
- Patients and carers told that staff are comfortable with the risks of discharging someone
while suicidal (despite the patient/carer not being comfortable)
- Patients and carers told that if the patient attempts suicide or self-harms while in hospital
they will be discharged (including patients detained under the Mental Health Act)
- Patients and carers told the patient is not at risk, despite the patient not previously being
known the Trust
- Patients and carers told the patient has “chronic” suicidal feelings, despite only being
suicidal for a few days or weeks
- Patients and carers told that staff could ‘defend their actions in a coroners court’ if the
patient died
- Carers admonished for encouraging patients to “attention-seek” by responding in a caring
manner when the person they care for harms themselves
- Carers told they are entirely responsible for the person they care for
- Carers told it’s better for Trust figures if the patient dies at home rather than in hospital
- Carers banned from calling the crisis team because they have raised concerns
- Carers banned from engaging in their relative’s care because they have raised concerns,
despite the patient’s expressed wish that they be involved
- Carers laughed at by staff for expressing concern for their relative
- Carers told to stop housing the patient (rendering them effectively homeless), as it is
reducing their responsibility for themselves
- Carers not listened to by services until the person they care for is seriously injured, missing
or dead
For example:
“They let me [leave the hospital] on home leave knowing I was having a really bad week,
and on home leave I overdosed, when I got taken back to westlane my psychiatrist told
me I wasn’t actually suicidal because if I was I would’ve taken more tablets and I
wouldn’t be alive.”
- TEWV Patient (bold ours)
When in hospital after ligatures etc. The CRISIS team would say [to my daughter] are
you going to try and kill yourself again. She would say yes. They would say we are
busy don’t do it tonight.
- Mum of TEWV Patient (bold ours)
“They [the crisis team] seem to refuse to believe our daughter was intent on suicide,
and no matter how many times she told them, no one would listen. This has been,
unfortunately, a running thread through everything for months; no-one will listen to us