The reason why we are here is that we do not believe that the current system serves the best interests of the relatives of those who die by suicide when they are in the community under compulsory treatment orders. The fatal accident inquiry system was reviewed last year and, in our opinion, a valuable opportunity to include such deaths was lost. Deaths by suicide while in NHS care under those orders in the community could have been covered by that review but they were not, although deaths in the prison system were. Fatal accident inquiries are now mandatory for all deaths in the prison system, but if you are out in the community and you die by suicide, it is really up to the NHS how it investigates the way that you died and the circumstances leading up to your death.
I will give you a bit of personal background. My son was ill for many years with schizophrenia. His final hospital admission was from March 2010 to April 2012. While he was in hospital, his illness took a severe turn. He did things that he had not done before, such as trying to severely damage himself. For a whole year, we were told, “He’s not suicidal.” He wrote final notes to us while he was in hospital. We were given them by the procurator fiscal six months after he died, when she found them in his files, yet the consultant was saying, “Your son’s not suicidal.”
Eventually, we complained. We said, “This can’t go on. My son’s harming himself and swallowing objects.” He was referred for surgery twice to have objects removed and we were still told that he was not suicidal. When we wrote to complain, the consultant was allowed to handle the complaint against him. He wrote back to me and said that perfectly sane people do these things.
After that year, my son was sectioned and transferred to Carseview, where I discovered that his medical records were totally incorrect. I corrected the records and was told that the corrections would stay with the records. That did not happen. Eventually, he was released on a compulsory community treatment order. He cancelled numerous appointments that we did not know about. One of the reasons why he was on the order was so that he would engage with the services and in that way they could ensure that he was staying well and safe in the community. Despite his cancelling those appointments and being anxious in the weeks leading up to his death, no one took any notice. No one did anything.
On the day that he died, he cancelled an appointment with the Scottish Association for Mental Health, which was supporting him. He left a message on the answering machine. SAMH reported that to his psychiatric nurse, who did nothing, again. I got home at 10 to 5 and found him hanging from his loft. On that day, he had been to his GP practice but his prescription for a drug called Orphenadrine, which was to stop his anxiety and restlessness in his limbs, was not available even though he had been promised the day before that it would be.
I am trying to build for you a picture of how various elements were involved in the lead-up to my son’s death by suicide. None of those elements has been satisfactorily examined for the sake of improving the system. Nothing that I do or say will bring back my son, my daughter’s brother or my grandson’s dad, but the fact is that the only way we can improve the system is by getting a process that can properly investigate the things that are going wrong.
NHS Tayside can decide for itself what kind of reports it does. Initially, it did a significant clinical event analysis—or SCEA—report, but it did not involve us, the GP practice or the mental health officer in that. In the first instance, I had to contact it and ask what it would do. It did not have any standard procedures in place.
When my son died, the procurator fiscal sent me a letter saying, “We are very sorry to hear of the death of your son. This is what will now happen”. The NHS had nothing like that. When I asked about that, it said that it had to update its Datix system or some such thing. The NHS did a report that covered the last six months of my son’s life but, even though it was kind of the same thing, it did not include the two years when he was in hospital but out on leave. He was under their care for two and a half years.
The NHS said that it would do a report, but because of the time that it was taking, I was advised by the Scotland Patients Association to talk to a solicitor. I talked to a solicitor, who got me a report by an independent expert. The NHS said, “Now that you’ve talked to a solicitor, we’re not doing any report on your son’s death. We’re finished here.” You might say, “Well, fair enough—you went to a solicitor,” but the independent report was all that we wanted. Our legal action stopped there. We could not afford to go any further and we did not want any more; we just wanted somebody to tell us what had happened. We knew that what had happened in my son’s case was not right, but we wanted a proper expert opinion. Once we had that, the NHS was able to say, “Well, we’re not doing this any more.”
For its own purposes, the NHS should be doing a complete report on anyone who dies by suicide while under its care in the community, so that it can review its systems and see what it could do better in the future and what perhaps should not have happened. It should do that for its purposes and not just for ours. It was within its power to say that it would do a report or not do a report.
The NHS produced an independent report for the procurator fiscal that in our opinion was an absolute whitewash—you have probably heard that before from many relatives of people who have died by suicide. The report listed all the appointments that my son had cancelled and said, “Well, that’s okay—he cancelled appointments. There was nothing we could have done.” The whole purpose of his being in the system was that there was something that they could have done. They should have had him reviewed and asked why he was cancelling appointments, but none of that happened.
My conclusion is that only a proper inquest-type investigation will lead to all the facts being established and that, if such an investigation is chaired by a truly independent body such as, perhaps, the Mental Welfare Commission for Scotland, it should lead to improvements in care and perhaps even save lives, which is what we all want. I do not want anyone else to go through what our family has been through.