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Found 141 results
  1. Content Article
    It highlights the findings from inquests that took place between January 2018 and April 2019, including that of Emily Hartley, Annabella Landsberg, Jessica Whitchurch, Natasha Chin, Nicola Jayne Lawrence and Sarah Maria Burke. Also included is updated statistics on the deaths in women's prisons, noting that there have now been 106 deaths (to 10 May 2019) since the 2007 Corston Review. To prevent deaths in women’s prisons, INQUEST is calling on government and parliamentarians, policy makers, practitioners and campaigners to recognise women’s imprisonment as a form of structural violence against women; honour international treaty obligations to safeguard vulnerable women and girls; and work together towards eradicating outdated and failing women’s prisons. Key INQUEST recommendations in the report: Redirect resources from criminal justice to welfare, health, housing and social care. Divert women away from the criminal justice system. Halt prison building and commit to an immediate reduction in the prison population. Review sentencing decisions and policy. An urgent review of the deaths of women following release from prison. Ensure access to justice and learning for bereaved families. Build a national oversight mechanism for implementing official recommendations.
  2. Content Article
    The new research maps the provision of safer custody telephone lines across the prison estate - dedicated phone lines which enable family members and others to pass on urgent information when they have concerns. It finds that provision is patchy, under-resourced and even non-existent in some prisons, leaving families struggling to share their concerns with prison staff. The report reveals that: Almost two in five (37%) prisons in England and Wales appeared to have no functioning dedicated safer custody telephone lines for families to get in touch. Of these, nearly one in five prisons (18%) had no publicly advertised number for a dedicated safer custody telephone line. A further 18% of prisons advertised a dedicated line, but when called the number either wasn’t operational, was not answered, or went through to a general prison switchboard. Of the 75 dedicated safer custody telephone lines that went through to safer custody departments, only 13 (17%) were answered by a member of staff. Over 80% of dedicated safer custody lines that went through to safer custody departments (62 prisons in total) put the caller straight through to an answer machine.
  3. Content Article
    The report makes the following recommendations: National review: the government should proceed with its national review of deaths of people on post-release supervision in the community following a custodial sentence to establish the scale, nature and cause of the problem. Data: more detailed and accurate data should be made available along with regular reporting to the Minister responsible and Parliament alongside the publication of an annual report. Investigations: deaths of people on post custody supervision should be investigated by an independent body with adequate resources allocated to allow this to happen. There needs to be a threshold for this with a range of factors taken into account. Improve scrutiny and learning: the Government needs to confirm oversight at a local and national level.
  4. Content Article
    Brooke was admitted to Chadwick Lodge on 15 April 2019 and had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder; she initially failed to engage and was violent to staff and self-harming. By the middle of May 2019 she had made progress. On 5th June 2019 she was found with a ligature around her neck, which was suspended from the door of her room. Following this incident consideration should have been given to a formal risk assessment to include consideration of her level of observation. The details of the incident should have been fully disclosed to the MDT meeting on 6 June and consideration given to increasing the level of observation. The incident should also have been discussed and disclosed to all members of staff caring for her. On 10 June 2019 Brooke Martin was found secretly fiddling with a bedsheet on two occasions by two different members of staff.. The bedsheet should have been removed and examined, that would have shown that a section of the sheet had been torn off. This would and should have resulted in a full risk assessment and search of her room, that would have resulted in an increase in her level of observations to 1:1 observations. Brooke Martin, if constantly observed or other safety measures put in place would not have been able to tie the ligature that caused her death and would not therefore have died on 11t June 2019. Coroner's concerns During the course of the evidence it was explained to the coroner that it had not been possible to access the notes and records from an out of area hospital because not all the health providers were using “System One”. It is a major concern that the various systems used throughout the NHS are not compatible with each other and it is not always possible for each healthcare provider to access the notes and records of the patient. This situation should be reviewed to see how access across the NHS can be gained to patient records when required. The coroner was told by one senior clinician that when a patient is referred to his specialist mental health unit it is often the case, that is 9 times out of 10, he does not receive all the information of the patient’s history. This would not be the case if he had direct access to the records.
  5. News Article
    A father whose son took his own life in July 2020 is calling for an "urgent overhaul" of the way some counsellors and therapists assess suicide risk. His son Tom had died a day after being judged "low risk", in a final counselling session, Philip Pirie said. A group of charities has written to the health secretary, saying the use of a checklist-type questionnaire to predict suicide risk is "fundamentally flawed". The government says it is now drawing up a new suicide-prevention strategy. According to the latest official data, 6,211 people in the UK killed themselves in 2020. It is the most common cause of death in 20-34-year-olds. And of the 17 people each day, on average, who kill themselves, five are in touch with mental health services and four of those five are assessed as "low" or "no risk", campaigners say. Tom Pirie, a young teacher from Fulham, west London, had been receiving help for mental-health issues. He had repeatedly told counsellors about his suicidal thoughts - but the day before he had killed himself, a psychotherapist had judged him low risk, his father said. Tom's assessment had been based on "inadequate" questionnaires widely used despite guidelines saying they should not be to predict suicidal behaviour, Philip said. The checklists, which differ depending on the clinicians and NHS trusts involved, typically ask patients questions about their mental health, such as "Do you have suicidal thoughts?" or "Do you have suicidal intentions?" At the end of the session, a score can be generated - placing the individual at low, medium or high risk of suicide, or rating the danger on a scale between 1 and 10. Read full story Source: BBC News, 20 April 2022
  6. News Article
    Children and young people who are anxious, depressed or are self-harming are being denied help from swamped NHS child and adolescent mental health services, GPs have revealed. Even under-18s with an eating disorder or psychosis are being refused care by overstretched CAMHS services, which insist that they are not sick enough to warrant treatment. In one case, a crisis CAMHS team in Wales would not immediately assess the mental health of an actively suicidal child who had been stopped from jumping off a building earlier the same day unless the GP made a written referral. In another, a CAMHS service in eastern England declined to take on a 12-year-old boy found with a ligature in his room because the lack of any marks on his neck meant its referral criteria had not been met. The shocking state of CAMHS care is laid bare in a survey for the youth mental health charity stem4 of 1,001 GPs across the UK who have sought urgent help for under-18s who are struggling mentally. CAMHS teams, already unable to cope with the rising need for treatment before Covid struck, have become even more overloaded because of the pandemic’s impact on youth mental health. Mental health experts say young people’s widespread inability to access CAMHS care is leading to their already fragile mental health deteriorating even further and then self-harming, dropping out of school, feeling uncared for and having to seek help at A&E. “As a clinician it is particularly worrying that children and young people with psychosis, eating disorders and even those who have just tried to take their own life are condemned to such long waits”, said Dr Nihara Krause, a consultant clinical psychologist who specialises in treating children and young people and who is the founder of stem4. “It is truly shocking to learn from this survey of GPs’ experiences of dealing with CAMHS services that so many vulnerable young people in desperate need of urgent help with their mental health are being forced to wait for so long – up to two years – for care they need immediately. Read full story Source: The Guardian, 3 April 2022
  7. News Article
    Burnout is not a strong enough term to describe the severe mental distress nurses and other NHS staff are experiencing, says a doctor who has led efforts to improve care for health professionals. Medical director of the NHS Practitioner Health service Dame Clare Gerada told MPs radical action was needed to improve the mental well-being of NHS staff. She said nurses and other healthcare staff should be entitled to one hour of paid reflective time per month to be written into NHS employees’ contracts, alongside mentoring, careers advice and leadership training built in throughout people’s careers. Dr Gerada was among senior clinicians who gave evidence this week to the Health and Social Care Committee, which is looking at issues around recruitment and retention of staff. She told the committee the term ‘burnout’ simply did not cover the level of stress and mental anguish experienced by NHS workers. ‘Burnout is too gentle a term for the mental distress that is going on amongst our workforce,’ she said. High suicide rates among nurses and doctors, high levels of bullying and staff being sacked because they have long-COVID are all signs the health service is failing to look after its employees, she said. ‘The symptoms we have got are the symptoms of an organisation that is unable to care for its workforce in the way that it should be caring,’ she said. Read full story Source: Nursing Standard, 25 March 2022
  8. News Article
    A patient at Broadmoor Hospital has died after suffocating while staff were chatting outside of his room, an inquest has heard. Aaron Clamp, a patient at the notorious high security mental health hospital Broadmoor, died on 4 January 2021 after asphyxiating whilst in his room. The Independent understands Mr Clamp’s death may have been the first “non-natural” death since the new Broadmoor Hospital, run by West London Trust, opened in December 2019. According to evidence heard at the inquest, staff who were meant to be carrying out continuous “eyesight” observations on Mr Clamp, were having a conversation without direct sight into his room. Mr Clamp’s father told The Independent he was “tormented” by the criminal justice and mental health system which resulted in his “indefinite incarceration.” “Diagnosed with a mental illness, schizoaffective disorder, the purpose of treatment was rehabilitation. Psychiatric treatment is conventionally centred on medication to manage symptoms and risk," his father said. He acknowledged there is a balance to be struck between managing risks and restricting patients, but closer attention of holistic compassionate care should be given. Read full story Source: The Independent, 3 March 2022
  9. News Article
    The death of a "vulnerable" transgender teenager who struggled to get help was preventable, a coroner has said. Daniel France, 17, was known to Cambridgeshire County Council and Cambridgeshire and Peterborough Foundation Trust (CPFT) when he took his own life on 3 April 2020. The coroner said his death showed a "dangerous gap" between services. When he died, Mr France was in the process of being transferred from children and adolescent mental health services (CAMHS) in Suffolk to adult services in Cambridgeshire. The First Response Service, which provides help for people experiencing a mental health crisis, also assessed Mr France but he had been considered not in need of urgent intervention, the coroner's report said. Cambridgeshire County Council had received two safeguarding referrals for Daniel, in October 2019 and January 2020, but had closed both. "It was accepted that the decision to close both referrals was incorrect", Mr Barlow said in his report. Mr Barlow wrote in his report, sent to both the council and CPFT: "My concern in this case is that a vulnerable young person can be known to the county council and [the] mental health trust and yet not receive the support they need pending substantive treatment." He highlighted Daniel was "repeatedly assessed as not meeting the criteria for urgent intervention" but that waiting lists for phycological therapy could mean more than a year between asking for help and being given it. "That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act," Mr Barlow said. Read full story Source: BBC News, 25 February 2022
  10. News Article
    Having Covid-19 puts people at a significantly increased chance of developing new mental health conditions, potentially adding to existing crises of suicide and overdoses, according to new research looking at millions of health records in the US over the course of a year. The long-term effects of having Covid are still being discovered, and among them is an increased chance of being diagnosed with mental health disorders. They include depression, anxiety, stress and an increased risk of substance use disorders, cognitive decline, and sleep problems – a marked difference from others who also endured the stress of the pandemic but weren’t diagnosed with the virus. “This is basically telling us that millions and millions of people in the US infected with Covid are developing mental health problems,” said Ziyad Al-Aly, chief of research and development at the VA St Louis Healthcare System and senior author of the paper. “That makes us a nation in distress.” The higher risk of mental health disorders, including suicidal ideation and opioid use, is particularly concerning, he said. “This is really almost a perfect storm that is brewing in front of our eyes – for another opioid epidemic two or three years down the road, for another suicide crisis two or three years down the road,” Al-Aly added. These unfolding crises are “quite a big concern”, said James Jackson, director of behavioural health at Vanderbilt University’s ICU Recovery Center, who was not involved with this study. He is also seeing patients whose previous conditions, including anxiety, depression and opioid use disorder, worsened during the pandemic. Read full story Source: The Guardian, 18 February 2022
  11. News Article
    Millions of patients in England face dangerously long waits for mental health care unless ministers urgently draw up a recovery plan to tackle a “second pandemic” of depression, anxiety, psychosis and eating disorders, NHS leaders and doctors have warned. The Covid crisis has sparked a dramatic rise in the numbers of people experiencing mental health problems, with 1.6 million waiting for specialised treatment and another 8 million who cannot get on the waiting list but would benefit from support, the heads of the NHS Confederation and the Royal College of Psychiatrists have told the Guardian. In some parts of the country, specialist mental health services are so overwhelmed they are “bouncing back” even the most serious cases of patients at risk of suicide, self-harm and starvation to the GPs that referred them, prompting warnings from doctors that some patients will likely die as a result. “We are moving towards a new phase of needing to ‘live with’ coronavirus but for a worrying number of people, the virus is leaving a growing legacy of poor mental health that services are not equipped to deal with adequately at present,” said Matthew Taylor, the chief executive of the NHS Confederation, which represents the whole of the healthcare system in England. “With projections showing that 10 million people in England, including 1.5 million children and teenagers, will need new or additional support for their mental health over the next three to five years it is no wonder that health leaders have dubbed this the second pandemic. A national crisis of this scale deserves targeted and sustained attention from the government in the same way we have seen with the elective care backlog.” One family doctor in Hertfordshire, Dr David Turner, said he was so concerned about the situation that he had chosen to speak out publicly for the first time in his 25-year career. “I and many other GPs feel the issue has become critical and it is only a matter of time before a child dies,” he told the Guardian. Turner said access to child and adolescent mental health services (CAMHS) was “never great pre-Covid” but was now “appalling”. The double whammy of a spike in demand and underinvestment in CAMHS was putting patients at risk, he added. Read full story Source: The Guardian, 21 February 2022
  12. News Article
    Inmates held in a women’s prison are making 1,000 calls a month to Samaritans amid record levels of self-harm, increased violence and low safety levels usually only seen in men’s facilities, a damning report has found. Nearly a third of women held at Foston Hall in Derbyshire, which holds 272 residents, told inspectors they felt unsafe, while the use of force in the prison has doubled over nearly three years and is the highest on the women’s prison’s estate. The women’s prison and youth offender institute is the first to be given a score of “poor” – the lowest – for the safety of female prisoners, since HM Inspectorate of Prisons developed its current framework more than a decade ago. Charlie Taylor, HM chief inspector of prisons, said the rating of “poor” for safety levels was a “rare and unexpected finding” in a women’s prison. Recorded levels of self-harm were also the highest in the women’s estate and two prisoners had taken their own lives since the last official inspection in February 2019, he said. “As an indicator of the level of distress, women were making 1,000 calls a month to Samaritans. The prison had no strategy to reduce self-harm or improve the care for those in crisis,” Taylor said. The response to women in crisis was too reactive, uncaring and often punitive, Taylor observed. “This, taken with other safety metrics and observation, meant it was no surprise that in our survey nearly a third of women told us they felt unsafe,” he said. The report also found that the majority of women who harmed themselves did not have enough support or activity and faced daily frustration in getting the help they needed. Read full story Source: The Guardian, 9 February 2022
  13. News Article
    The class B drug ketamine could help to treat people suffering from severe suicidal thoughts, a study has suggested. Researchers from the University of Montpellier in France said the sedative could save lives, as it appears to alleviate dark thoughts in patients admitted to hospital for their mental health. The finding was based on a controlled trial involving 156 adults with severe suicidal ideas, which ran from April 2015 to March 2019 in seven French teaching hospitals. The participants included people with bipolar disorder and major depressive disorder. However, patients with a history of schizophrenia were excluded from the study. Although the team found the side effects of ketamine were minor and had diminished by day four, they cautioned that more research was needed to examine its benefits. “Ketamine is a drug with a potential for abuse. Longer follow-up of larger samples will be necessary to examine benefits on suicidal behaviours and long term risks,” they wrote. Commenting on the study, Riccardo De Giorgi, a PhD student at the University of Oxford, said: "These findings indicate that ketamine is rapid, safe, and effective in the short term for acute care in hospitalised suicidal patients.” Read full story Source: The Independent, 4 February 2022 Ketamine for the acute treatment of severe suicidal ideation: double blind, randomised placebo controlled trial
  14. News Article
    The number of people who try suicide has risen steadily in the U.S. But despite gains in health coverage, nearly half are not getting mental health treatment. Suicide attempts in the United States showed a “substantial and alarming increase” over the last decade, but one number remained the same, a new study has found: Year in and year out, about 40% of people who had recently tried suicide said they were not receiving mental health services. The study, published in JAMA Psychiatry, traces a rise in the incidence of suicide attempts, defined as “self-reported attempts to kill one’s self in the last 12 months,” from 2008 to 2019. During that period, the incidence rose to 564 in every 100,000 adults from 481. The researchers drew on data from 484,732 responses to the federal government’s annual National Survey on Drug Use and Health, which includes people who lack insurance and have little contact with the health care system. They found the largest increase in suicide attempts among women; young adults between 18 and 25; unmarried people; people with less education; and people who regularly use substances like alcohol or cannabis. Only one group, adults 50 to 64 years old, saw a significant decrease in suicide attempts during that time. Among the major findings was that there was no significant change in the use of mental health services by people who had tried suicide, despite the passage of the Affordable Care Act in 2010 and receding stigma around mental health care. Over the 11-year period, a steady rate of about 40%t of people who tried suicide in the previous year said they were not receiving mental health care, said Greg Rhee, an assistant professor of psychiatry at the Yale School of Medicine and one of the authors of the study. The Affordable Care Act, which took effect fully in 2014, required all health plans to cover mental health and substance abuse services, and also sharply reduced the number of uninsured people in the U.S. However, many respondents to the survey in the new report said the cost of mental health care was prohibitive; others said they were uncertain where to go for treatment or had no transportation. “It is a huge public health problem,” Dr. Rhee said. “We know that mental health care in the U.S. is really fragmented and complicated, and we also know not everybody has equal access to mental health care. So, it’s somewhat not surprising.” Read full story (paywalled) Source: New York Times,19 January 2022
  15. News Article
    A string of failings may have contributed to the death of a “deeply vulnerable” law student who killed herself while being treated in a psychiatric hospital in Bristol, an inquest jury has said. Zoë Wilson, 22, had informed staff she was hearing voices in her head telling her to kill herself and 30 minutes before she died was seen by a nurse through an observation hatch looking frightened and behaving oddly but nobody went into her room to check her. Speaking after the jury’s conclusions, Wilson’s family said that Avon and Wiltshire mental health partnership NHS trust (AWP) should face criminal charges over the case. AWP said it accepted it had fallen short in its care of Wilson. Zoë on the 17 June 2019 she told staff she was hearing voices telling her to kill herself and handed over an item that she could have used to harm herself with. She was not moved to an acute ward and other items that she could have used were not removed. At 1am on 19 June she was observed standing beside her bathroom door looking frightened but staff did not go to her. Thirty minutes later she was checked again and had harmed herself. Emergency services were called but she was pronounced dead. Giving evidence to Avon coroner’s court, the nurse who saw Wilson at 1am said he had only worked in the unit a handful of times and had not met Wilson before that night. The jury concluded that steps taken to keep her safe that night had been inadequate and also criticised communication and information sharing. In a statement, her family, said: “Zoë was a wonderful, bright, and deeply vulnerable young woman. She was on a low-risk ward even when she told staff that voices in her head were telling her to kill herself.” They called for AWP to face a criminal prosecution by the Care Quality Commission (CQC). “We will continue to fight for justice in her name,” they said. “She will never be forgotten.” Read full story Source: The Guardian, 27 January 2022
  16. News Article
    A vulnerable woman judged to be at medium risk of self harm was on a mental-health ward that catered for low-risk patients, an inquest heard. Zoe Wilson, 22, died on the Larch Ward at Bristol's Callington Road Hospital in June 2019 after being found unconscious in her room at 01.30 BST. She had previously told staff that voices were telling her to kill herself, her inquest heard. Healthcare assistant Sarah Sharma found her and immediately called for help. Addressing a jury inquest at Avon Coroners' Court, she said that "patients admitted to Larch should have all been low risk". This meant they would "preferably" have hourly observations by staff and be able to take their medication without any issues. Many were ready to be discharged and they were there because something was holding them up, normally housing, she said. The experienced healthcare assistant said if the patient's risk increased they should be placed under "one to one" monitoring with a member of staff until they were moved to a more suitable unit. The inquest heard earlier that Ms Wilson had been judged to be medium risk and was placed on 30-minute observations on 18 June. Her risk level was re-assessed when she handed a belt to staff and informed them voices were telling her to kill herself. Ms Sharma told the court that she was on her first overnight shift in two and a half weeks that night, and was informed in a handover that Ms Wilson was at risk of self-harming. Having never met Ms Wilson - who had schizophrenia - she queried what kind of self-harm the patient was at risk of but said the nurse performing the handover told her he "didn't know". Ms Sharma told the inquest she was unaware of the belt incident or that Ms Wilson had not been sleeping well and had requested medication to calm her down. Read full story Source: BBC News, 24 January 2022
  17. News Article
    GPs should regularly review self-harm patients and offer a specific CBT intervention, according to a consultation on the first new guidance for self-harm to be drawn up in 11 years. The new draft guidance emphasises the importance of referring patients to specialist mental health services, but stresses that, for patients who are treated in primary care, continuity is crucial. If someone who has self-harmed is being treated in primary care, GPs must ensure regular follow-up appointments and reviews of self-harm behaviour, as well as a medicines review, the draft guideline say. They must also provide care for coexisting mental health issues, including referral to mental health services where appropriate, as well as information, social care, voluntary and non-NHS sector support and self-help resources. The guidance says that referring people to mental health services would ‘ensure people are in the most appropriate setting’. However, the committee agreed that ‘if people are being cared for in primary care following an episode of self-harm, there should be continuity of care and regular reviews of factors relating to their self-harm to ensure that the person who has self-harmed feels supported and engaged with services’. The draft guidance, out for consultation until 1 March, also says ambulance staff should suggest self-harming patients see their GP to maximise the chance of engagement with services. It says: ‘When attending a person who has self-harmed but who does not need urgent physical care, ambulance staff and paramedics should discuss with the person (and any relevant services) if it is possible for the person to be assessed or treated by an appropriate alternative service, such as a specialist mental health service or their GP.’ It notes that ‘ambulance staff often felt that the emergency department was not the preferred place that the person who had self-harmed wanted to be taken. They agreed that referral to alternative services could facilitate the person’s engagement with services’. Read full story Source: Pulse, 18 January 2022
  18. News Article
    A nurse who was struck off for refusing to admit a woman to a mental health unit before she killed herself said 'leave her, she will faint before she dies' before he kicked her out of the facility. Paddy McKee allegedly made the comment as Sally Mays, 22 - who had mental health issues - tried to strangle herself when she was refused admission. Ms Mays killed herself at home in Hull in July 2014 after being refused a place at Miranda House in Hull by McKee and another nurse. Despite her being a suicide risk, they would not give her a place at the hospital after a 14-minute assessment. Her parents Angela and Andy have fought for several years for improvements to be made and lessons to be learnt from her death. McKee was this month struck off following a Fitness to Practice hearing conducted by the Nursing and Midwifery Council. The report by the NMC was this week published and condemned McKee, saying 'he treated her in a way that lacked basic kindness and compassion'. The NMC found his actions to refuse Ms Mays' admission had contributed to her death. Read full story Source: Mail Online, 12 January 2022
  19. News Article
    Hundreds of children suffering from mental health issues are attending A&E each day, with some waiting up to five days in emergency departments, The Independent can reveal. Internal NHS data leaked to The Independent, shows the number of young patients waiting more than 12 hours from arrival has also more than doubled in the last year. A national survey of senior A&E doctors by the Royal College of Emergency Medicine (RCEM) found in some areas children’s mental health services have worsened in the last three years, while the majority of respondents warned there were no children’s crisis services open after 5pm. One NHS trust chief executive has warned his hospital’s A&Es have seen a “real surge” in both attendances of people with severe mental health issues and a sharp increase in long waits in recent months. One parent, Lee Pickwell, told The Independent his daughter was admitted to paediatric wards several times and stayed days in an emergency “section 136” unit while she waited more than two months for a mental health bed. Dr Mark Buchanan, RCEM’s lead for children’s mental health, told The Independent that despite improvements, children’s mental health services still fall short of what is needed. Dr Buchanan said: “I’ve seen children who have been not seen by Child and Adolescent Mental Health Services (CAMHS), who been refused the referrals, despite the fact that the mum and dad were taking it in turns to sleep outside their bedroom door because they were scared that they’d run away and do some harm.” Read full story Source: The Independent, 13 July 2022