Transcript Document

The call for
A Parliamentary Commission into
Perinatal Mental Health Care in the UK
Presented by Chris Bingley
Charity Registration
Number: 1141638
JBMF – Founders Statement
Joanne, or Joe as she preferred to be called, was a nurse with
over 20 years experience. She was dedicated, caring and diligent
as are most health care professionals I have met.
But Joanne was let down by the very NHS organisation that she
gave everything to and just 10 short weeks after giving birth to
her much longed for daughter Emily, whilst being treated at
home for severe postnatal depression she took her own life.
“The Joanne Bingley Memorial Foundation is a charity
that exists to ensure future generations such as my
daughter have access to the appropriate care and
support, that services adhere to care quality standards
and to inspire sustainable change in the perception and
provision of maternal mental health services in the UK”
Parliamentary Commission
Into Perinatal Mental Health
Where we are at:
The requirement for such a commission has been voiced between various MPs and 3rd sector
organisations over the last 2 years but taking proposals forward had to wait until the NHS
accepted the legal claims regarding the treatment and death of Joanne (Joe) Bingley.
Scope & Proposals Agreed with the Head of Health at Policy Connect
Timeline and Plans Outline agreed with Policy Connect, who will run the Parliamentary Commission
Current Support
Various cross-party MPs have agreed their support
- including Barry Sheerman, MP for Huddersfield and Char of Policy Connect
A selection of 3rd sector organisations have reviewed plans and agreed their support
- using Dads as the link to focus on the impacts felt upon the whole family
Funding
£100,000 required, (grants and funding bids in progress)
Next Steps
Confirm Funding
Identify Steering Group Members
Launch of Parliamentary Commission in 2015
Parliamentary Commission
Into Perinatal Mental Health
Proposed Scope and Terms of Reference: The inquiry will provide an independent
review and detailed investigation to understand and highlight the issues and policy areas
Why? has there been a failure to implement Specialist Perinatal Mental Health Care Services across the UK
despite Parliamentary and Department of Health promises after the death of Daksha Emson.
Why? has there been a failure to implement “lessons learned” from Independent Investigations and
Confidential Enquiries and a failure to implement and follow Care Standards.
Why? Dads are not being recognised as Carers by NICE even though “Home Care” is the primary treatment
offered by Mental Health Crisis Teams (Note use of the term …. “Significant Others”)
What? are the implications and costs to society and the economy:
• Mums - unnecessary “Suffering in Silence” and “Avoidable Deaths”
• Dads – “Caring for Partners” and “suffering from PND”
• Early Years Child Development – issues in the 1001 Critical Days
• The breakdown of Family Finances, Family Relationships and Resulting Deprivation
• Businesses Productivity and Employer Costs
• The “Consequences of Failure” on the wider community and general public
What? are the required actions to enforce the implementation of Care Standards and Lessons Learned, and
to ensure promises made are delivered.
What? are the recommendations to reduce the “unnecessary suffering” and “avoidable deaths”
Why ….?
Joanne (Joe) Bingley
• Joe was a dedicated and caring nursing professional
• Trained initially through Huddersfield Royal
Infirmary to qualify as a Registered Nurse, then
completed an Honours Degree at Huddersfield
University
• She spent 20 years working at Huddersfield Royal
Infirmary where she was Sister on day surgery.
• 10 weeks post-partum, whilst being treated at home
suffering for severe PND, Joe committed suicide
• Her funeral attended by over 400 people included
ex-patients and many of her colleagues from HRI
• I felt all their eyes on me asking the same question
that I kept asking myself…
Why ?
Daksha Emson Public Enquiry
In 2003 following the release of the public enquiry into the suicide of the
psychiatrist Dr Daksha Emson and infanticide of her child, the government
made promises that the NHS would deliver “Specialists In Perinatal Mental
Health” to care for women in crisis who suffer from postnatal depression.
The Royal College of Psychiatry created the faculty of Perinatal Mental Health
as a specialism.
Yet more than 10 years after the Public Enquiry:
•
More than 35,000 mums are left suffering in silence every year
•
Mums are too scared to come forward for treatment for fear of having
their child taken away
•
Dads are left supporting Mums who are too scared to seek help or turn to
health care professionals
•
Health Care Professionals are still asking for “Specialists In Perinatal
Mental Health” and access to services so that they can support mums,
dads and families suffering the mental trauma and crisis
Confidential Enquiries
The Confidential Enquiries into Maternal Death are recognised as the
“gold standard” in in investigating the cause of mums death and
they detail how Postnatal Depression is not a new problem:
•
2002 Confidential Enquiry into Maternal Deaths highlights suicide as a
result of postnatal depression a leading cause of maternal death.
•
A plethora of policies, guidelines and legislations follow:
•Carers Acts 1990, 1995, 2000, 2005
•Specialised Mental Health Services (2004)
•National Service Framework Maternity Standard 11 (2004)
•Perinatal Healthcare in Prison – A Scoping Review of Policy and Provision (2006)
•NICE Guidelines CG90 Depression in Adults (2007) revised (2009)
•NICE Guidelines CG45 Antenatal and Postnatal Mental Health (2007)
•NHS Acts, Human Rights Act, The NHS Constitution (Health Act 2009)
•
2011 Confidential Enquiry into Maternal Deaths - suicide is still the leading
cause of maternal death.
Coroners Inquest – Oct 2011
The criminal standard of proof beyond reasonable doubt, represents the evidential
hurdle or threshold that the coroner had to consider for suicide or unlawful killing. He
resolved to return a narrative verdict, and his 21 statements of fact include:
•
A personal and family history of mental health problems as well as significant adverse life
events befalling her in the last 5 years of her life. (Including prior treatment for PND)
•
By the 22nd April her condition was such that she was referred to the Mental Health Services
who responded promptly. At and around this time she was expressing suicidal ideation, low
mood, anxiety and a poor sleep pattern.
• At a meeting it was determined she could be treated at home. I have found as fact that no
discussion of other therapeutic options took place………informed consent has not been
obtained.
•
Independent medical care advice commissioned from Dr Oates and Mr Ketteringham. I have
accepted their view that the possibility of admission should have been part of the initial
treatment care plan and discussed with the patient and her husband as a treatment option if
she either became worse or did not improve.
•
I find as fact that her health fluctuated and did not improve.
•
It is also their evidence that on the 27 April, if not before, there was clinical indication to be
admitted to a Mother and Baby Unit. (i.e. 3 days before she died)
• It would follow from this opinion that if admission had taken place Joanne Bingley
in all probability would not have died on the date or in the manner that she did.
Mums continue to die as
Lessons Learned not Implemented
The Independent Investigation into Joanne (Joe) Bingley’s death resulted in 21
recommendations for improvement i.e. “lessons learned”, which the NHS trusts agreed
in an action plan with her husband Chris to implement in full the by September 2011.
After being told by NHS staff actions had not been implemented as the NHS trust had
told him, Chris’ requested the Care Quality Commission to investigate.
In April 2012 the Care Quality Commission, following complaints raised by the husband
of a patient who had deceased, reported on the NHS Trust that treated Joe:
• their investigation found the NHS Trust had “failed to implement” many of the
“Lessons Learned” and many “failed to meet acceptable care standards”
• Mums suffering severe PND – “Women in this specific user group at risk”
3 Deaths in 4 years of mums referred as patients to the same NHS Mental Health Trust
Following the CQC report, at least 2 further mums died whilst suffering from severe
postnatal depression / psychosis receiving treatment at home by the same NHS Trust.
• Jan 2013 Clair Tuprin, Sheffield
Treated at home for severe PND, jumps from John Lewis building in Sheffield
• Dec 2013 Roaseanne Hinchlife,
Treated at home for puerperal psychosis, sneaks out and Jumps from Cliffs at Whitby
The NHS Constitution (Health Act 2009)
On 19 January 2010 The Health Act 2009 came into force placing a statutory
duty on NHS bodies, primary care services, independent and third sector
organisations in England. The Constitution clarifies “patient rights” such as:
Informed Consent
• To be able to give valid consent to treatment is a fundamental right and absolutely central in all forms of
health care.
• You have the right to be involved in discussions and decisions about your healthcare, and to be given
information to enable you to do this.
• So a patient can make “informed decisions” they need access to impartial, evidence based, accurate,
readable, information.
• This is especially important when a person has severe depression.
Treatment Options
• Patients have the right to be treated with a professional standard of care, by appropriately qualified and
experienced staff.
• You have the right to drugs and treatments that have been recommended by NICE for use in the NHS, if your
doctor says they are clinically appropriate for you.
• You have the right to be given information about your proposed treatment in advance.
Learning by Experience
• You have the right to expect NHS organisations to monitor, and make efforts to improve, the quality of
healthcare they commission or provide.
• In the case of an NHS body or private organisation, it must take reasonable care to ensure a safe system of
healthcare – using appropriately qualified and experienced staff.
Negligence Claims and
NHS Legal Costs (Joe Bingley)
In December 2013, nearly 4 years after her death, the Director of Nursing from the NHS
trust that treated Joanne (Joe) Bingley finally admitted negligent liability for her death.
2 years after the Coroner issued his “Statement of Facts”, In a statement issued into
court the NHS accepted that:
• In all probability had specialist perinatal psychiatric treatment been offered,
including the admittance to hospital in a specialist mother and baby unit, it would
have been accepted.
• Had specialist treatment been provided the patient, Joanne Bingley, would have
been expected to make a full recovery.
• Their (NHS Trusts) breach in duty of care was the probable cause of death
1/5th the NHS budget currently goes to cover negligence claims with £1.8bn spent
annually in legal costs defending negligence claims ……….
• Whilst stating their desire to settle the claim, 4 years after her death NHS lawyers
have yet to agree “heads of agreement” prior to discussing the value of any claim
• Joe’s husband had the family home repossessed and faces bankruptcy with his own
legal costs currently in excess of £400,000, with estimates of total legal costs > £1m.
A National Scandal
The death of Joanne (Joe) Bingley highlights a national scandal
• The Patients Association Survey in 2011 found more than 50% of Mental
Health Services acting in breach of care standards
– failing to follow care quality standards,,
– failing to employ the required specialist perinatal psychiatrists,
– failing to provide information to patients
– NICE guidelines specify that those who suffer severe postnatal depression
should be referred to a specialist perinatal psychiatrist
– less than 37% of PCTs commissioned specialist services.
– NICE Guidelines state the preferred treatment for severe PND or Puerperal
Psychosis is hospitalisation in Mother and Baby Units (MBUs)
– less than 91 beds exist with places for a maximum of 593 mums
– 10% Dads suffer Postnatal Depression, Dads are not recognised by NICE
– no specialist services are available for Dads either as Sufferers or Carers
Despite Ministerial promises, NHS Service Frameworks, NICE Care Standards
and various Guidelines. ………… the NHS has failed to commission Perinatal
Mental Health Services across most of the UK.
Why things remain unchanged
According to The Confidential Enquiries into Maternal Death the highest cause
of maternal death is suicide as a result of suffering depression.
86% of deaths are “avoidable deaths” based upon findings that it was possible to have
identified the illness and provided treatment for the Mums to have made a full recovery.
The sad facts are:
•
The stigma associated with suffering mental illness has not gone away
•
Mental illness does not get “parity of care” with physical illness
•
NHS Primary Care Trusts failed to commission perinatal mental health
services across more than 50% of the country (1)
•
Huge gaps and discrepancies in provision of services across the UK (3)
•
Currently 97% of Health and Well Being Boards in England have failed to
include any strategy on Perinatal (Maternal) Mental Health.
This is WHY – outcomes for most patients have remained unchanged for 10 yrs
Parliamentary Commission
Into Perinatal Mental Health
Proposed Scope and Terms of Reference: The inquiry will provide an independent
review and detailed investigation to understand and highlight the issues and policy areas
Why? has there been a failure to implement Specialist Perinatal Mental Health Care Services across the UK
despite Parliamentary and Dept Health promises after death of Daksha Emson.
Why? has there been a failure to implement “lessons learned” from Independent Investigations and
Confidential Enquiries and a failure to implement and follow Care Standards.
Why? Dads and Significant Others are not being recognised as Carers by NICE even though “Home Care” is
the primary treatment offered by Mental Health Crisis Teams
What? are the implications and costs to society and the economy:
• Mums - unnecessary “Suffering in Silence” and “Avoidable Deaths”
• Dads – “Caring for Partners” and “suffering from PND”
• Early Years Child Development – issues in the 1001 Critical Days
• The breakdown of Family Finances, Family Relationships and Resulting Deprivation
• Businesses Productivity and Employer Costs
• The “Consequences of Failure” on the wider community and general public
What? are the required actions to enforce the implementation of Care Standards and Lessons Learned, and
to ensure promises made are delivered.
What? are the recommendations to reduce the “unnecessary suffering” and “avoidable deaths”
The Joanne (Joe) Bingley
Memorial Foundation
 Founders Statement
 How we help
 Why I am here ……
JBMF – Founders Statement
Joanne, or Joe as she preferred to be called, was a nurse with
over 20 years experience. She was dedicated, caring and diligent
as are most health care professionals I have met.
But Joanne was let down by the very NHS organisation that she
gave everything to and just 10 short weeks after giving birth to
her much longed for daughter Emily, whilst being treated at
home for severe postnatal depression she took her own life.
“The Joanne Bingley Memorial Foundation is a charity
that exists to ensure future generations such as my
daughter have access to the appropriate care and
support, that services adhere to care quality standards
and to inspire sustainable change in the perception and
provision of maternal mental health services in the UK”
JBMF – How we help
How the foundation delivers it’s aims:
• Website and information leaflets - we provide information on what you
need to know so dads, grandparents and friends can help.
• We publish stories in national media, Twitter, Facebook and our
website to encourage open discussion and raise awareness
• Knowledge of ‘Best practice’ – legislation, care quality protocols,
befriender and peer support groups, self help, supervision, etc;
presenting at seminars and workshops to inform commissioners, dept
health, parliament, etc. on patient and service issues.
• We provide training & education workshops for professional health
care workers and volunteers
• We have supported research including:
• The Patients Association survey of Primary Care Trusts
• Kings College User Group
• Through links with MP’s and other organisations we inform NHS policy
makers and parliament of service user issues and expectations
• Supporting the Maternal Mental Health Alliance we work with other
organisations to deliver improvements in PNMH services.
Why I am here ……