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Found 141 results
  1. Content Article
    The report's key findings show that: 229 women died during or up to six weeks after the end of their pregnancies in 2018 – 2020 from pregnancy-specific causes or conditions made worse by pregnancy, an increase of 24% compared to 2017-2019.Taking into account their surviving babies and previous children, 366 motherless children remain. Of the 229 women who died during or up six weeks after the end of their pregnancies, nine women died from COVID-19. Of those nine women, five were Asian women and three were Black women. Changes to maternity services and pressures because of the pandemic also contributed to some other maternal deaths. Black women were 3.7 times more likely to die compared to White women and Asian women were 1.8 times more likely to die compared to White women. A further 289 women died between six weeks and one year after the end of pregnancy. Including the deaths of 18 women who died during pregnancy or up to six weeks after pregnancy which were classified as coincidental, in total, there were 536 maternal deaths among 2,101,829 maternities. One in nine of the women who died had experienced severe and multiple disadvantage. The main elements of a multiple disadvantage were: a mental health diagnosis; substance misuse; and domestic abuse. The report notes that the figures reported are likely to be a minimum estimate due to inconsistencies in reporting these types of disadvantage. Women were three times more likely to die by suicide during or up to six weeks after the end of pregnancy in 2020 compared to the 2017 – 2019 report. Maternal suicide was also a leading cause of death in women between six weeks and a year of their pregnancies ending, accounting for 18% of the women who died between 2018 and 2020. At least half of the women who died by suicide and the majority from substance misuse had multiple adversity with a history of childhood and/or adult trauma frequently reported. Cardiovascular disorders and psychiatric disorders are now equally responsible for maternal deaths in the UK, accounting for 30% of the women who died up to six weeks after the end of pregnancy; in previous reports, cardiovascular disorders have been reported as the leading direct cause of maternal death. 86% of the women died in the postnatal period. The report demonstrates that even when the women who died as a result from COVID-19 are excluded, the number of women who died has still increased by 19% compared to 2017 – 2019, suggesting that an even greater focus on the report's recommendations for improvements to maternal healthcare are needed.
  2. News Article
    Ministers may order a public inquiry into mental health care and patient deaths across England because of the number of scandals that are emerging involving poor treatment. Maria Caulfield, the minister for mental health, told MPs on Thursday that she and the health secretary, Steve Barclay, were considering whether to launch an inquiry because the same failings were occurring so often in so many different parts of the country. They would make a final decision “in the coming days”, she said in the House of Commons, responding to an urgent question tabled by her Labour shadow, Dr Rosena Allin-Khan. An independent investigation found this week that that three teenage girls – Christie Harnett, 17, Nadia Sharif, 17, and Emily Moore, 18 – took their own lives within the space of eight months after receiving inadequate care from the Tees, Esk and Wear Valleys (TEWV) NHS mental health trust in north-east England. They died after “multifaceted and systemic failings” by the trust, especially at its West Lane hospital in Middlesbrough, the inquiry found. Allin-Khan pointed to a series of scandals that have come to light, often through media investigations, about dangerously substandard mental health care being provided by NHS services and also private firms in England, including in Essex and in Greater Manchester. “Patients are dying, being bullied, dehumanised, abused and their medical records are being falsified, a scandalous breach of patient safety,” Allin-Khan said. “The government has failed to learn from past failings.” Read full story Source: The Guardian, 3 November 2022
  3. News Article
    Three teenage girls died after major failings in the care they received from NHS mental health services in the north-east of England, an independent investigation has found. “Multifaceted and systemic” failures by the Tees, Esk and Wear Valleys (TEWV) NHS trust contributed to the young women’s self-inflicted deaths within eight months of each other, it concluded. Christie Harnett died aged 17 on 27 June 2019 at the trust’s West Lane hospital in Middlesbrough. Nadia Sharif, also 17, died there six weeks later, on 5 August. Emily Moore, who had been treated there, died on 15 February 2020 at a different hospital in Durham. All three had complex mental health problems and had been receiving NHS care for several years. The investigation into their deaths, commissioned by the NHS, found that 119 “care and service delivery problems” by NHS services, especially TEWV, had occurred. Charlotte and Michael Harnett, Christie’s parents, said their daughter had “lost her life whilst in a hospital run by TEWV trust where there was little or no care or compassion”. Emily’s parents, David and Susan Moore, said she received “horrific care” while at West Lane. Services at the hospital were understaffed, “unstable and overstretched”, the investigation’s final report found. Both families, and also Nadia’s parents, Hakeel and Arshad Sharif, said the dangerous inadequacy of the care provided by TEWV, and the likelihood that other patients with fragile mental health had died as a result, showed that ministers should order a full public inquiry. “This mental health trust is a danger to the public,” the Moores said. The report said TEWV failed to properly monitor the girls, given their known risk of self-harm; to take seriously concerns about their care and suicide risk raised by their families; and to remove all potential ligature points. Read full story Source: The Guardian, 2 November 2022
  4. News Article
    One in 10 patients undergoing fertility treatment experience suicidal thoughts “all the time”, a survey suggests. Fertility Network UK, which carried out the poll, said the findings reveal the “far-reaching trauma” of experiencing infertility and undergoing IVF in the UK. Four in 10 respondents - 98% of whom were women - said they had experienced suicidal feelings. Gwenda Burns, chief executive of Fertility Network UK, said: “Fertility patients encounter a perfect storm: not being able to have the child you long for is emotionally devastating. "But then many fertility patients face a series of other hurdles, including potentially paying financially crippling amounts of money for their necessary medical treatment, having their career damaged, not getting information from their GP, experiencing their relationships deteriorate, and being unable to access the mental support they need." “This is unacceptable. Infertility is a disease and is as deserving of medical help and support as any other clinical condition.” Three in four patients said their GP did not provide sufficient information about fertility problems and treatment. Read full story (paywalled) Source: The Telegraph, 31 October 2022
  5. News Article
    The mother of a bullied 12-year-old girl has said her daughter struggled to get mental health support on the NHS in the months before she killed herself, and accused her school of failing to deal with inappropriate messages circulating among pupils. The mother of Charley-Ann Patterson, Jamie, told a hearing that despite being seen by three medical professionals, Charley-Ann had been unable to get mental health support in the months before her death. In a statement read at an inquest at Northumberland coroner’s court on 12 October, Jamie said her daughter had changed halfway through her first year of secondary school, when she was sent “inappropriate” and “shocking” messages by other pupils. The inquest heard that Jamie first took her daughter to a GP over self-harm concerns in June 2019, but she said she “did not believe that the GP took Charley-Ann’s self-harm seriously, potentially due to her age”. She took Charley-Ann to A&E in May 2020 after a second episode of self-harm, where she was referred to a psychiatric team and given a telephone appointment in which she was told Charley-Ann would be referred to child and adolescent mental health services (CAMHS), but that “it was likely that she would not be seen for three years”. In an appointment with a nurse she was told that she would be referred to the Northumberland mental health hub for low mood and anxiety, but later learned “that this referral was never made”. Read full story Source: The Guardian, 12 October 2022
  6. Content Article
    1. Centre for Mental Health briefing: Poverty, economic inequality and mental health (26 July 2022) This briefing paper by the think tank Centre for Mental Health explores the links between factors that worsen mental health. It highlights evidence showing that living in poverty increases people’s risk of mental health difficulties, and that more unequal societies have higher overall levels of mental ill health. It also highlights inequalities in access to primary care and mental health services across the UK and demonstrates how economic inequality combines with structural racism to undermine the mental health of marginalised groups in society. 2. Self-harm: assessment, management and preventing recurrence (NICE, 7 September 2022) This new guideline from the National Institute for Health and Care Excellence (NICE) covers assessment, management and preventing recurrence for children, young people and adults who have self-harmed. It includes those with a mental health problem, neurodevelopmental disorder or learning disability and applies to all sectors that work with people who have self-harmed. The guideline sets out some important principles for care and treatment. For example, it states that self-harming patients treated in primary care must receive regular follow-up appointments, regular reviews of self-harm behaviour and a regular medicines review. 3. People with eating disorders should not face stigma in the health system and barriers to accessing support in 2022: A blog by Hope Virgo In this blog, Hope Virgo, an eating disorder survivor and mental health campaigner, looks at the barriers people face when they try to access support, and talks about her own experience of being told she was ‘not thin enough for support’. She calls for long-overdue action on funding, training and awareness of eating disorders within the NHS. 4. Commission on Young Lives - Heads Up: Rethinking mental health services for vulnerable young people (29 July 2022) This detailed report by the Commission on Young Lives examines the state of children and young people's mental health in the UK, describing the current situation as "a profound crisis." It examines the impact of the pandemic on young people's mental health, as well highlighting the lack of capacity and inequalities present in children and young people's mental health services. It then looks in detail at factors that contribute to mental health issues in children and young people and prevent marginalised groups from accessing mental health support. 5. Rethinking doctors’ mental health and the impact on patient safety: A blog by Ehi Iden This blog by Ehi Iden, hub topic lead for Occupational Health and Safety, reflects on the increasing workload and pressure healthcare professionals face, the impact this has on patient safety and why we need to start 're-humanising' the workplace. He highlights that, “It takes a safe healthcare worker to deliver safe healthcare to patients.” 6. Risk of suicide after dementia diagnosis (3 October 2022) This research study looks at the association between a dementia diagnosis and suicide risk in the general population and identifies high-risk subgroups. The authors of the study found that dementia was associated with increased risk of suicide in patients diagnosed before the age of 65 years, those in the first three months after diagnosis and those with known psychiatric comorbidities. 7. Zero Suicide Alliance training The Zero Suicide Alliance is a collaboration of NHS trusts, charities, businesses and individuals who are committed to suicide prevention in the UK and beyond. Their website offers free online training courses to teach people the skills and confidence to have potentially life-saving conversations with someone they’re worried about. They offer short online modules covering general suicide awareness, social isolation and suicide in veterans and university students. 8. Blog: Shifting the dial on mental health support for young black men (6 April 2022) In this blog for NHS Confederation, Kadra Abdinasir talks about how mental health services have failed to engage with young black men, and describes how services need to change to overcome the issue. She argues that delivering effective mental health support for young black men requires a move away from a crisis-driven response, to investment in system-driven, community-based projects. Kadra looks at learning from Shifting the Dial, a three-year programme recently piloted in Birmingham as a response to the growing and unmet needs of young black men aged 16 to 25. A recent report on the project found that most young men involved in Shifting the Dial reported good outcomes related to their wellbeing, confidence, sense of belonging and understanding of mental health. 9. Running hot: the impact of the pandemic on mental health services (21 February 2021) The Covid-19 pandemic has had a significant impact on people’s mental health, and the knock-on effect is putting services and organisations under considerable pressure. In this briefing for the NHS Confederation, Paula Lavis outlines the case for change in mental health services and makes recommendations on how to address the increasing demand. 10. Blog: Why harmful gender stereotypes surrounding men’s approaches towards their feelings need challenging This blog explores why men are reluctant to seek support when they are struggling with their mental health and why the suicide rate is so high. It looks at initiatives that exist to encourage men to seek help and highlights what more could be done to support mens’ mental health.
  7. News Article
    People who have recently been diagnosed with dementia, or who are diagnosed with the condition at a younger age, are among those at increased risk of suicide, researchers have found. The findings have prompted calls for greater support for those experiencing such cognitive decline. While previous research has explored a potential link between dementia diagnosis and suicide risk, the results have been inconclusive, with some suggesting a raised risk and others a reduced risk. Now researchers say certain groups of people with dementia are at increased risk of suicide. “What it tells us is that period immediately after diagnosis is when people really need support from the services that provide the diagnosis,” said Dr Charles Marshall, co-author of the research and a clinical senior lecturer and honorary consultant neurologist at the Wolfson Institute of Population Health at Queen Mary University of London. In the first three months after being told they had dementia, those diagnosed before the age of 65 had an almost seven times greater risk of suicide compared with those without dementia – although this reduced somewhat over time. Marshall said it was unclear whether the findings were down to dementia itself causing people to feel suicidal, or factors such as people being concerned they may become a burden to their family. Read full story Source: The Guardian, 3 October 2022
  8. Content Article
    The final guideline mirrors the draft guidance in advising that self-harming patients, when treated in primary care, must receive: regular follow-up appointments regular reviews of self-harm behaviour a regular medicines review. The guidance also said: After an episode of self-harm, the format and frequency of initial aftercare and which services will be involved must be discussed with the patient. If the psychosocial assessment after a self-harm episode was made by a GP, initial aftercare must be provided by the GP within 48 hours of the assessment. GPs should use consultations and medicines reviews as ‘an opportunity to assess self-harm if appropriate, for example, asking about thoughts of self-harm or suicide, actual self-harm, and access to substances that might be taken in overdose (including prescribed, over-the-counter medicines, herbal remedies and recreational drugs)’. Reiterating existing guidance, the guideline added: ‘Do not offer drug treatment as a specific intervention to reduce self-harm.’
  9. News Article
    Nearly 38,000 vital follow-up appointments with mental health patients were missed at the time when they were most at risk of suicide, the Royal College of Psychiatrists has said. The medical body has called for “urgent action” to ensure more people are seen for follow-ups within 72 hours of their discharge from inpatient care, to prevent them from falling “through the cracks when they are so vulnerable”. The risk of suicide is highest on the second and third days after leaving a mental health ward, but 37,999 follow-up appointments with patients were not made within this timeframe in England between April 2020 and May 2022. According to NHS data, of the 160,430 instances when patients were eligible for follow-up care within 72 hours after discharge from acute adult mental health care, only three-quarters (76%) took place within that period. The Royal College of Psychiatrists is calling for more trained specialists to check on those perceived to be at risk, which they say requires more staffing and funding. The president of the Royal College of Psychiatrists, Dr Adrian James, said: “We simply can’t afford to let people fall through the cracks at a time when they are so vulnerable. It’s vital that our mental health services are properly staffed and funded to offer proper follow-up care and help prevent suicides. “Staff are working as hard as they can to provide high-quality care, but it’s clear that current resources are not enough to meet these targets. We need urgent action to tackle the workforce crisis and achieve the suicide prevention goals set out in the NHS long-term plan.” Read full story Source: The Guardian, 22 August 2022
  10. News Article
    Deaths, staff shortages and a culture of life-threatening self-harm are exposing deep fears about the quality of mental health care in hospitals for children and young people. Since 2019, at least 20 patients aged 18 or under have died in NHS or privately-run units, the BBC has found. A further 26 have died within a year of leaving units, amid claims of a lack of ongoing community support. The NHS said it had "invested record amounts... to meet record demand". Child and Adolescent Mental Health Services (CAMHS) units look after about 4,000 patients with many different diagnoses each year. The aim is to help them recover over a period of weeks or months through specialist care. Some patients are in and out of the units for years. The BBC has also heard serious claims regarding the unsafe discharge of patients sent home from CAMHS hospitals. Several former patients told the BBC they had serious self-harm incidents or tried to take their own life within days of returning home. Parents have described being on "suicide watch" 24 hours a day, to ensure their child's safety. Read full story Source: BBC News, 9 August 2022
  11. News Article
    People would rather go to England if they had a stroke than use the A&E at a north Wales hospital, a health watchdog has said. Inspectors said there was a "clear and significant risk to patient safety" after inspections at the department in Ysbyty Glan Clwyd, Denbighshire. North Wales Community Health Council's Geoff Ryall-Harvey said it was the "worst situation" they had seen. The report said inspectors found staff who were "working above and beyond in challenging conditions" during a period of "unrelenting demand". Many staff told them they were unhappy and struggling to cope. They said they did not feel supported by senior managers. However inspectors said that the health board was not fully compliant with many of the health and care standards, and highlighted significant areas of concern, which could present an immediate risk to the safety of patients, including: Doctors were left to "come across" high-risk patients instead of being alerted to them. Patients were not monitored enough - including a suspected stroke patient and one considered a suicide risk. Children were at serious risk of harm as the public could enter the paediatric area unchallenged. Inspectors found evidence of children leaving unseen or being discharged against medical advice. Betsi Cadwaladr health board said it was committed to improvements. Read full story Source: BBC News, 8 August 2022
  12. Event
    We have known for several years that nurses are at higher risk of suicide than the general population and that nurses have more job-related problems recorded prior to death by suicide. What we have now learned about those job-related problems is troublesome at best with implications for risk managers, hospital executives, and all leaders in healthcare. The panel in the Patient Safety Association webinar will describe the issues and implications for advocacy and policy change necessary to right the wrongs leading to death by suicide amongst nurses through personal testimony and review of recent research findings. This webinar is sponsored by CHPSO. By the end of the session, the participants will be able to: Identify major issues stemming from the workplace that lead to death by suicide. Identify institutional, professional, and individual actions that can be taken to reduce risk. Describe the flaws in the current system that prevent accurately tracking and action-planning to reduce risks amongst nurses. Register
  13. Event
    A screening of 'DO NO HARM', a 60-minute documentary that discusses physician burnout and suicide followed by a 60-minute panel discussion. Doctors take an oath to save lives, yet they are taking their own at an alarming rate, trapped in a toxic healthcare system that puts their patients' lives at risk. This film and panel discussion bring awareness to the topic of this epidemic that's been covered up for decades until now. Register
  14. Content Article
    What is the Skills and Support Toolkit? The online toolkit written by INQUEST, is an interactive resource that aims to build a range of skills, from organising information relating to the inquest, speaking in public, to handling media attention. Families have helped to create the skills toolkit, giving bereaved individuals the much needed support and ability to communicate their concerns and calls for change. "The Skills and Support Toolkit can provide you with practical advice needed to continue and maintain your day to day life at a time when even the simplest of tasks can seem insurmountable, or help you develop the skills needed to mount a campaign." - Mother of a child who died in prison.
  15. Content Article
    What does the handbook cover? It includes advice and information on: What happens after a sudden death? Post-mortem examinations and the rights of bereaved people The process before and during an inquest, including when you may need legal advice and how to fund it Coping with a death and an inquest Contentious deaths in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question Contacts of voluntary, government and professional organisations working on mental health, criminal justice and immigration issues. About INQUEST INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Their specialist casework includes deaths in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question.
  16. Content Article
    This thematic review presents a detailed analysis of claims made after an individual has attempted to take their life.Claims relating to completed suicide and attempted suicide are reviewed, regardless of whether the claim resulted in financial compensation. It identifies common problems with care and provides recommendations for improvement to support service delivery. Results The results are split into two parts. The first part analyses the problems identified from the clinical details of each claim and the second part analyses the quality of the serious incident reports. Part one identifies recurring clinical themes and areas for improvement. Five areas where there were common issues in clinical care are discussed in depth: substance misuse communication, particularly failures in intra-agency working risk assessment observations prison healthcare. Part two identifies four main areas of concern, where: There was a lack of family involvement and staff support through the investigation and inquest process. The quality of root cause analysis undertaken as part of the Serious Incident (SI) investigation was generally poor and did not focus on systemic issues. Due to the poor SI report quality, the recommendations arising from SI investigations were unlikely to reduce the incidence of future harm. Reports to prevent future deaths (PFDs) were issued to trusts by the coroner with little consistency and there were poor mechanisms to ensure that changes in response to the PFDs had been made or addressed the issues highlighted.
  17. Content Article
    The report argues for a fundamental rethink about the use of prison and calls for a political boldness to implement evidence-based change. The vulnerabilities of young prisoners have been well documented by countless research, investigations and inquest findings, yet they continue to be sent to unsafe environments, with scarce resources and staff untrained to deal with their needs. Based on INQUEST's specialist casework with the families of the prisoners who died, the report found that: 83% were classified as “self-inflicted”. The highest number of deaths occurred in HMYOI Glen Parva (six) and HMP Chelmsford (four). A further casework sample of 47 young and child deaths also found that: 30% of those who died were care leavers or had suffered some kind of family breakdown which required them to live outside of their immediate family home. 70% had mental health issues and 49% had self-harmed previously. A critical concern is that prison establishments have not learned lessons from previous deaths in prisons; too many deaths occur because the same mistakes are made time and again. In the light of these concerns, this report considers the implications and reasons behind prison deaths since 2011. Lastly, the report stresses the need for new thinking and new strategies if such deaths are to be avoided in the future.