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Case Study

Desperate pleas for help to mental health team at Surrey and Borders Partnership NHS Foundation Trust ignored

The sister of a 50-year-old woman who hanged herself after repeatedly begging for help from the NHS mental health Crisis Helpline has said that the family's urgent requests for help, plus those of a therapist treating the woman, were ignored.

Jo Blackwell, who had recent history of mental illness, committed suicide by hanging on 19th January 2017 at the home of her 81-year-old aunt in Camberley, Surrey after begging for help from an NHS mental health team in the weeks before her death and calling the crisis helpline seven times four days before she died.

Two days before Jo died, a mental health clinician decided she was at low risk of suicide having seen her and performed a standard assessment.

Jo's sister, Dr Nikki Blackwell, an associate professor of critical care, said the mental health team at Surrey and Borders Partnership NHS Foundation Trust had failed her sister, not least when Nikki rang them from Australia, four days before Jo’s suicide clearly stating that her sister was acutely homicidal and suicidal.

"My sister told me over the phone that she planned to kill our aunt, 'bash our father's head in with a hammer' and then kill herself.  I know that I clearly described how acute the situation was, because that's part of my job. I made an impassioned request for my sister to be admitted to hospital but this was the response recorded in the notes:

"Contact CMHRS (community mental health recovery service) informing them of contact with Crisis Helpline; Information disclosed by her sister Nicky, will refer to HTT if feels is needed today, have informed Nicky will need to speak with client first'.

"I had spoken to my sister earlier and she was so frightened, she was sitting in her car, trembling," Nikki said. "It was the sickest I've ever heard her. I also had a friend in the car with me when I made the call who was incredulous at the low-key response to what was clearly a dangerous crisis, asking, 'what do you have to do to get help?'"

Jo's music therapist, to whom she turned in times of crisis, also documented in the week before Jo’s death that Jo showed a new resolve for suicide.

A clinical assessment of Jo four days later concluded that she was not ill enough to be admitted to hospital, even though she had also called the Helpline seven times two days earlier, begging for help.

Jo, who had ongoing problems with alcohol, and anorexia, split her time between living with father and her aunt. Her aunt also called the community health team that week saying she no longer felt safe in her own home.

Nikki says the notes do not nearly reflect the depth of concern she expressed over the phone. "I felt she (one of the mental health team) wasn't really listening, as if she was doing something else at the same time.

"I desperately wanted Jo sectioned, their suggestion was that she go to the Safe Haven cafĂ©, when she was clearly far too unwell to drive.  The situation was clearly escalating, but no one reacted properly."

The log clearly states that Nikki told the team that Jo 'feels she is the Devil and feels she could kill her father'. Nikki believed Jo would be urgently referred to a psychiatrist and the Mental Health team would speak to aunt and father for collateral information, neither of which happened.

The day before she died, Jo called her sister and said her feet were swelling. The next day, her father, who suffers dementia and Parkinson's, called to say Jo had committed suicide by hanging a few hours after the call the previous day.

Paul McNeil representing the family at the inquest said there would be no civil claim against the trust. "The family just wants the truth about what happened to Jo and to make sure significant changes in practices are implemented to make sure no-one else has to go through such an appalling situation as this."

Nikki Blackwell said, "We're not looking to blame individuals here, however my sister had asked for review by a psychiatrist and a further trial of medications at least a month before she died. She then called the crisis line in despair, and lost all hope of receiving help. In the weeks before her death there were multiple missed opportunities to intervene; I believe her death could have been prevented."

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