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Joanne

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Joanne s Story: A Reason to Act Presented by Chris Bingley Charity Registration Number: 1141638 * * * Our Vision The foundation exists to inspire & motivate change ... – PowerPoint PPT presentation

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Title: Joanne


1
Joannes Story A Reason to Act Presented by
Chris Bingley
Charity Registration Number 1141638
2
Why I am here
3
The Utter Devastation of Loss !
  • Grief is a process . you have to keep going to
    get through it?
  • Everything is dark, you can see no end, you have
    to find strength within you
  • Follow a path until you find light. or find help
  • http//www.uk-sobs.org.uk/
  • 1 Corinthians 13 .faith, hope and love and the
    greatest of these is love !
  • Love .. your best friend is gone, taken herself
    away from you
  • Hope .. there is none, your dreams and plans
    destroyed
  • Faith .. shattered by the knowledge that these
    are avoidable deaths
  • When nothing is left what do you live for?
  • Emily .. Was too young to have a bond, babies
    just cry, eat, sleep and pooh!
  • There is nothing left .?

4
My Inspiration
  • My Inspiration
  • Anthony Harrison, Angela Harrison Trust
  • You can make it through the grief
  • Dr Margaret Oates, on reporting the findings of
    her Independent investigation into Joes death
  • It needs someone who has suffered to stand-up
    and shout out
  • .. people listen to patients with a voice.its
    a powerful voice
  • Katherine Murphy, The Patients Association Chief
    Executive
  • We need one voice . professionals, charities
    and user organisations together
  • Albert Pike,
  • What we have done for ourselves alone dies with
    us
  • What we have done for others and the world
    remains and is immortal

5
Why I am here
6
Why am I doing this.
  • The Reasons
  • Emily Jane Bingley could be another
  • - Avoidable and Unnecessary Death ?
  • NHS failure to follow care quality standards, NHS
    Policies, National Service Frameworks and UK law
  • The lack of justice and accountability
  • Hundreds of potentially unlawful deaths and
    unnecessary suffering
  • I must protect my daughters life
  • .. when she has children
  • The People
  • Daksha Emson 10 years on Mums still die
    avoidable and unnecessary deaths
  • (MP, Secretary for Health empty promises)
  • Guidelines are just guidelines we dont have to
    follow guidelines These things just happen
    .
  • (NHS prior to investigating Joes
    Death)
  • NHS and Dept Health failure to properly
    investigate and to follow due process
  • Other Mums, Mental Health Patients and the
    General Public at risk
  • I ask myself ..Who else cares?

7
Why ?
Charity Registration Number 1141638
8
Why .?
  • Why Joe?
  • Joe was dedicated and caring nursing professional
  • Trained initially through Huddersfield Royal
    Infirmary and then deciding to complete an Hons
    Degree at Huddersfield University
  • She spent 20 years working at Huddersfield Royal
    Infirmary where she was Sister on day surgery.
  • 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 ?

9
A National Scandal
  • The death of Joanne (Joe) Bingley highlights a
    national scandal
  • Over the last 10 years, despite Ministerial
    promises, the development of NHS Service
    Frameworks and NICE Guidelines the NHS has failed
    to commission Perinatal Mental Health Services
    across more than 50 of the country.
  •  
  • Mental Health Services are acting unlawfully,
    failing to follow care quality standards, to
    implement safe systems of work, to employ the
    required specialist perinatal psychiatrists, to
    inform patients of their rights and to inform
    patients of the risks of their treatment.
  •  
  • The failure to provide appropriate care places
    more than 22,000 mothers a year at risk, with
    many unnecessary and potentially unlawful deaths.
  •  
  • Many Mental Health patient suicides and homicides
    are avoidable and potentially a result of
    unlawful treatment and care.
  • 10 of Dads suffer from postnatal depression but
    the NHS provides no support

10
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.

11
Whats going wrong?
  • Care Standards
  • Joes Pathway to Despair
  • The NHS Response After Joe Died
  • NHS Internal Reviews
  • The Independent Investigation
  • Coroners Inquest

12
Care Standards
  • Postnatal Depression is not a new problem !
  • 2000 Perinatal Mental Health created a specialist
    area by Royal College of Psychiatry following the
    death of Dr Daksha Emson and her baby.
  • 2002 Confidential Enquiry into Maternal Deaths
    highlights suicide as a result of postnatal
    depression the 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)
  • 2010 Confidential Enquiry into Maternal Deaths -
    suicide is still a leading cause of maternal
    death.

13
Joes Pathway to Despair ...1 of 3
  • 2008 Previous termination, miscarriages and
    treatment for depression documented in Health
    Visitor records NONE of the 5 mental health
    risk assessments described in the Kirklees
    Maternal Mental Health Care Pathway as the
    responsibility of Health Visitors completed, in
    breach of care quality standards and safe systems
    of work.
  • 18 Feb 2010 Emily Jane Bingley Born
  • 22 Feb 2010 Breast Feeding problems 1st
    Hospital stay with positive results
  • 10 Mar 2010 Breast Feeding problems 2nd
    Hospital stay
  • The medical records detail Joes un-consolable
    crying, anxiety, feelings of failure and the
    suspicions of Midwife she was suffering postnatal
    depression. But no clinical risk assessments
    completed, no referral and no information given
    to patient or husband
  • Treatment for her lack of hind milk and crying
    baby was to have Joe connected to a milk pump
    between feeds with intent to increase milk
    production over 10 days.
  • Treatment concentrated solely on the problems of
    Joe continuing to breast feed.
  • 14 Apr 2010 Easter Holiday emotional breakdown
  • GP diagnosis and starts drug treatment for
    Postnatal Depression and lack of sleep
  • 22 Apr 2010 Suicidal feelings and intent plans
    to drive herself and baby into a wall
  • GP listens to options considered but ruled out as
    they would not guarantee death
  • Mental Health Crisis Team contacted, diagnosis
    severe postnatal depression

14
Joes Pathway to Despair 2 of 3
  • 22nd April - At initial assessment home care
    recommended as course of treatment with no other
    treatment options considered or discussed. No
    written information of any kind provided nor any
    information on support groups or how to care for
    wife.
  • 23rd April - Care Plan provided to the patient
    and the husband marked as provided to The
    Carer. But no information provided about Carer
    Rights and no Carers Risks Assessment as
    required by The Carers Acts, in breach care
    quality standards
  • At no point is any referral made to specialist
    perinatal psychiatric services or to a consultant
    of any kind, in beach of care quality standards
    and NHS Frameworks
  • 27th April The Independent Investigation states
    that the clinical evidence substantiate that Joe
    should have been hospitalised at least 3 days
    before she died
  • Coroners Evidence regarding the visit by the
    Care Team that day
  • When Joe requested please take me with you her
    request was ignored and brushed aside by the care
    worker treating her that day. In the same meeting
    Joe left the session unexpectedly (withdrawing
    from the treatment). Despite Joes medical record
    detailing her suicidal plans, a decline in mental
    health and her obvious state of anxiety the care
    worker never explored Joes state of mind. Whilst
    sat in her car ready to leave, the husband
    knocked on the care workers window to explain Joe
    had left the property without telling anyone.
    Despite having recorded the husbands anxiety and
    distress in her notes, knowing his wife was
    suicidal, she told him to contact the police if
    his wife did not return and then drove away!

15
Joes Pathway to Despair 3 of 3
  • 29th April
  • Mental Health Crisis Team Dr and Nurse visit AM
    husband (The Carer) not attending but patients
    mother in attendance
  • The Dr for the first and only time during the
    entire treatment records signs of improvement,
    and decides there is no need to discuss alternate
    treatments
  • Health Visitors visit PM - husband (The Carer)
    not attending but paternal grandparents in
    attendance
  • Recorded high levels of anxiety, despair,
    inability to cope, her feelings that mental
    health service wasting her time and her intent to
    withdraw from care
  • HV contacts Crisis Team Manager who over rules HV
    concern and ignores risks
  • HV raises her concerns of HVs being unable to
    cope as she is told Crisis Team is planning to
    stop providing support, and she contacts her
    manager to log risks.
  • No-one contacts Husband (The Carer) to inquire of
    patients state or discuss risks prior to the Bank
    Holiday weekend.
  • 30th April 2010 - Joanne walks on railway
    tracks, throwing herself under a train
  • 4th May 2010 - On first day back at 905am the
    Crisis Team Manager contacts the Health Visitors,
    the medical records detail the purpose was to
    explain that at no time did Joanne show suicidal
    intent else they (The Crisis Team) would have
    taken action.

16
The NHS Response after Joe died
  • Huddersfield Royal Infirmary
  • - Excess stamp duty to pay for
  • - Letter of condolesnces and apology for your
    loss
  • Mental Health Crisis Team Admin Dept
  • - Patient Satisfaction Questionaire?
  • - Reminder to complete Patient Satisfaction
    Questionaire?
  • Mental Health Crisis Team Manager in discussion
    recorded by Health Visitor
  • Patients husband has family support so do not
    contact for 6 to 8 weeks
  • Support for Crisis Team staff and HV staff
    affected to be organised through normal channels
  • Mental Health Crisis Team Director and Manager ,
    in a meeting held in the patients home with her
    husband and GP friend, prior to investigating
    Joes death

17
NHS Internal Reviews
  • Huddersfield Royal Infirmary - Maternity Care
  • The report fails to address key issues and
    aspects of the treatment, failed to interview key
    persons who treated the patient, in particular
    the 2 Breast Feeding Midwives who were
    encouraging a course of treatment when it was
    suspected she was showing signs and symptoms of
    Post Natal Depression.
  • The conclusions are fundamentally flawed, stating
    we could not have known she was suffering from
    postnatal depression, contrary to the written
    evidence in the medical records and statements of
    the midwives.
  • Kirklees Community Healthcare Health Visitor
    Maternity Services
  • The report was written on the 4th May as an
    Internal Review without reference to any
    specific terms of reference or other guidance.
  • The report fails to cover key issues (Joes
    previous history and treatment for PND, the
    failure to perform 5 clinical risk assessments,
    etc.) making NO conclusions.
  • South West Yorkshire Partnership Foundation Trust
    Mental Health Services
  • Finds internal processes were followed and
    concludes whilst key things need to be improved
    nothing that was wrong contributed to the death.
  • The report fails to cover key issues and aspects
    of the treatment and care concentrates on
    internal policies and process failing to cover
    independent investigations, legislation, etc
    report emphasises the reliance on the family

18
The Independent Investigation
  • Due to time constraints it was agreed
  • The investigation team was only able to review
    the clinical documentation and policy documents
    without the benefit of investigators interviewing
    staff
  • As the Primary Care Trust were unable to
    facilitate the input into the investigation of
    specialists in Midwifery or Health Visiting, if
    there was a need these areas would be reviewed
    and investigated at a later stage.
  • The Independent Investigation concludes
  • From the documentation there is evidence that
    Joanne Bingley should have been hospitalised on
    the 27th of April 2010 at least 3 days before her
    death. Further if she had been so treated would
    probably have made a full recovery
  • The Results
  • 21 recommendations and actions for change
    including
  • Specialist Perinatal Psychiatric Resource
  • New strategies and policies compliant to care
    quality standards
  • New and improved systems, processes and safe
    systems of working
  • Provision of written information to patients and
    carers
  • Mandatory contractual care standards and
    compliance measures

19
Coroners Inquest
  • 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.
  • 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
    placeinformed consent has not been obtained.
    (one of many unlawful acts)
  • 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.
  • 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.

20
All Babies Count Spotlight on Perinatal Mental
Health
  • Spotlight on Perinatal Mental Health
  • Mother and Baby Units
  • NHS Constitution - Informed Consent
  • The Patients Association Report 2011
  • Equitable Access to Universal Services
  • Training and Education
  • NHS Constitution Learning by Experience
  • Independent Surveys
  • Maternity Services Unlawful
  • Mental Health Services Unlawful
  • Failing and Unlawful NHS Trusts
  • The Whole Family Approach
  • The Consequences of Failure
  • The True Costs of Failure
  • Mums and Dads at Risk
  • Best Practice Treatment
  • 3rd Sector Services

21
(No Transcript)
22
Spotlight on Perinatal Mental Health
  • The NSPCC report, part of the Prevention in Mind
    series, is a thorough and provocative review of
    the state of UK Maternal Mental Health services,
    co-authored with the Maternal Mental Health
    Alliance.
  • It highlights -
  • The NHS failure to comply with Care Quality
    Standards and failure to deliver on previous
    government promises.
  • The current postcode lottery and inequitable
    access to Maternal Mental Health care services
    results in over 35,000 mums suffering in silence
    every year.
  • The avoidable deaths of many mums and the dads
    left picking up the pieces with little to no
    support when a family lifes are torn apart.
  • The annual economic costs of mental illness in
    England have been estimated at 105.2bn
  • The costs of just a single avoidable death,
    such as Joanne Bingley, far out ways the economic
    and social costs of not providing the necessary
    Maternal Mental Health care services mums and
    dads need.
  •  

23
Mother and Baby Units
  • According to the NHS publication Birth to Five
    Years all mothers suffering from very severe
    postnatal depression or puerperal psychosis
    should be offered treatment in a mother and baby
    unit, unless there is a valid clinical reason for
    not doing so.
  •  
  • In the tragic case of Joann (Joe) Bingley -
  • At one point Joe asked the crisis team nurse
    "please take me with you. At the inquest the
    Coroner heard how her requests were ignored and
    when Joe walked out of the treatment session the
    nurse failed to follow-up with any questions as
    to Joes mental state. Whilst sat in her care
    ready to leave, when told that Joe had
    disappeared and left the property, she told Joes
    husband Chris to contact the police if Joe did
    not return and then drove away.
  • The Coroner issued a "Statement of facts" that
    accepted the Independent Investigation
    conclusions.
  •  
  • He agreed with them that the option of admission
    to a Mother and Baby Unit should have been
    discussed with Joe and Chris as part of
    agreeing the treatment option. He stated as fact
    that if Joe had been informed about this option
    in all probability she would have asked for and
    accepted this treatment and she would still be
    alive today. 
  •  
  • The coroner stated that the failure to inform Joe
    of the NICE recommended treatment options was a
    failure to obtain informed consent 
  •  
  •  

24
NHS Constitution Informed Consent
  • On 19 January 2010 The Health Act 2009 came into
    force placing a statutory duty on NHS bodies,
    primary care services, and 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.
  • This is especially important when a person has
    severe depression.
  • 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.
  •  
  • There is a need to raise awareness of Mother and
    Baby Units such as the one in Leeds so that mums
    are informed about this specialist service that
    is available.
  • The lack of beds and the difficulty patients have
    in accessing such treatment is no doubt a
    significant factor in the failure to reduce the
    incidence of mothers dying,
  •  

25
The Patients Association (2011)
  • The Patients Association investigation into
    Primary Care Trusts (PCT) commissioning of
    perinatal mental health services found that
  •  
  • 78 of PCTs do not know the incidence of PND in
    their region
  • 55 of PCTS are failing to follow NICE guidance
    and do not provide any written information on PND
    to mothers who may be suffering
  •  
  • 44 of PCTs are failing to implement NICE
    guidance and are not part of a clinical network
    for perinatal mental health
  •  
  • 63 of PCTs do not have a lead in PND services
    that is a Specialist Perinatal Psychiatrist as
    required by the NHS National Service Framework
  •  
  • 20 of PCTs do not review adherence to NICE
    guidelines
  • Service provision for women with postnatal
    depression can be poor to non-existent in most
    areas of the UK resulting in a postcode lottery
    of care.
  •  
  • 4Children reported in 2012 how 35,000 women (50
    of those who suffer from postnatal depression)
    are left suffering in silence many too afraid to
    seek help unsure of the treatment they will
    receive.
  •  

26
Equitable Access to Universal Services
  • This latest report from the NSPCC confirms that
    to end the current postcode lottery of care there
    is an urgent need to ensure ALL MENTAL HEALTH
    TRUSTS CONFORM TO NICE CARE QUALITY STANDARDS,
  •  
  • At the time of Joes death the Kirklees Primary
    Care Trust (PCT) had failed to commission
    specialist perinatal mental health services in
    accordance with NHS guidelines. 
  •  
  • The Patients Association report in March 2011
    into Primary Care Trusts found this was the case
    across more than 50 of the country with mental
    health trusts failing to follow care quality
    standards.
  • Those treating my wife were not trained,
    qualified or experienced specialists and failed
    to provide the recommended treatment in
    accordance to NHS Service Frameworks and NICE
    Care Quality Standards.
  • The NHS estimate the costs of outstanding
    negligence claims as a result of patient blunders
    and the NHS failure to follow care quality
    standards totals greater than 1/5th of the annual
    NHS annual budget or over 17.5bn .
  •  

27
Training and Education
  • The Mid-Staffordshire enquiry is just one of many
    Independent Reports raising issue that many NHS
    trusts are failing to comply with care quality
    standards, failing to adhere to professional
    standards of care and are operating unlawfully.
  •  
  • Following Joes death the Strategic Health
    Authority reluctantly agreed to an Independent
    Investigation into her death.
  • This resulted in 21 recommendations and actions
    to be implemented and concluded Joes was one of
    many avoidable deaths.
  • In April 2012 the Care Quality Commission
    published their findings following a review of
    the Mental Health Trust that had treated Joe
    Bingley. What they identified was appalling
  • Staff still not trained or qualified to provide
    the specialist perinatal mental health services
  • Planned training to be provided those unqualified
    and in-experienced in perinatal mental health
  • Where recommendations had been implemented many
    fell below care quality standards
  • The failure to implement several recommended
    actions that had been signed-off as complete.

28
NHS Constitution Learning by Experience
  • The NHS Constitution places legal duties on NHS
    trusts and their directors to provide services
    that comply with NICE care quality standards and
    that they implement the Lessons Learned from
    independent investigations.
  • 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.
  • The Care Quality Commission reported in April
    2012 -
  • Because the planned training in relation to
    perinatal mental health disorders is insufficient
    and is being delivered by trainers who lack
    experience in this area of work, there are risks
    that the Trusts staff will not be sufficiently
    equipped to safely meet the needs of this
    specific service user group.
  •  
  • The failure to apply lessons learned and to
    implement learning by experience along with the
    failure to adhere to care quality standards are
    grounds to claim unlawful death !
  •  

29
Independent Surveys
  • Following the Patients Association Survey in
    2011 many other independent surveys detail the
    poor and inadequate provision of perinatal mental
    health services and unlawful NHS Trusts in many
    areas
  • 2011 Confidential Enquiry into Maternal death
  • Mental illness still one of the highest causes of
    maternal death
  • 2011 National Perinatal Mental Health Project
    Report
  • Women not receiving help in accordance with
    national care quality guidelines
  • 2011 4Children Suffering in Silence
  • 35,000 women are suffering in silence with the
    condition each year, having a devastating effect
    on their lives, and the lives of their families.
  • A staggering half of all women suffering from
    postnatal depression do not seek any professional
    treatment, and thousands more are not getting the
    right treatment quickly enough.
  • 2012 The Tax Payers Alliance
  • Nearly 12,000 fewer people would die each year if
    the NHS matched quality standards in Europe, this
    should be a wake-up call for politicians
  • The issue is not a matter of spending more money
    as the UK spends considerably more than many
    other European countries.

30
Maternity Services Unlawful
  • Care Quality Commission
  • The CQC reported in November 2011 their
    inspection of 100 NHS trusts Maternity Services
    found
  • 20 NHS Trusts providing Maternity Services in
    Breach of The Law
  • An "embedded culture" of poor care and
    unprofessional behaviour
  • Catastrophic failings by NHS staff to provide
    basic care to patients.
  •  
  • Cynthia Bower, whilst Chief Executive of the Care
    Quality Commission, confirmed in writing -
  • The CQC does not have the power or authority to
    act upon complaints of unlawful treatment or
    gross negligence that have been raised in cases
    such as Joes.
  • That ultimate responsibility for the failure of
    Directors of or NHS Trusts rests with the
    Minister of State for Health.

31
Mental Health Services Unlawful
  • The Patients Association
  • The Patients Association reported in March 2011
    their investigation into commissioning of
    Perinatal Mental Health Services across 150 PCTs
  • 78 of PCTs do not know the incidence of PND in
    their region
  • 55 of PCTS are failing to follow NICE guidance,
    are not providing written information on PND to
    mums who may be suffering
  • 44 of PCTs are failing to implement NICE
    guidance, are not part of a clinical network for
    perinatal mental health
  • 63 of PCTs do not follow the NHS National
    Service Framework, have no Specialist Perinatal
    Psychiatrist to lead PND services
  • The result is over 50 of Mental Health Teams
    providing Perinatal Mental Health treatments are
    acting unlawfully.
  • There are legal obligations to inform Patients
    and Carers of their rights as well as legal
    obligations to inform patients of their treatment
    options. The information should be in writing and
    include whether treatment follows clinical
    standards, what risks are involved in accepting
    each treatment option and the information must be
    made available before treatment begins.

32
Failing and Unlawful NHS Trusts
  • Joanne (Joe) Bingley Case Study
  • NHS failure to recognise trends, to learn
    lessons, mistakes with similar issues and
    recommendations recurring across a large numbers
    of deaths and trusts
  • Of 17 Independent Investigations conducted by
    Yorkshire Humber SHA over a 4 year period, 11
    incidents (65) involve similar treatment
    factors, recommendations and action plans as the
    Independent Investigation into Joe Bingleys
    death
  • National Media Reports
  • Mental Health Trusts failure to follow NHS
    policy, NICE Care Quality Standards and
    professional and clinical standards of care
  • Avon and Wiltshire Mental Health Partnership
    Foundation Trust
  • Lincolnshire Partnership NHS Foundation Trust
  • South West Yorkshire Partnership Foundation
    Trust
  • Legislation and Due Process
  • The NHS has and is failing to follow due legal
    process, to acknowledge and conduct
    investigations in accordance with the NHS
    Constitution and failing to report incidents per
    the Health and Safety Executive and Crown
    Prosecution Service guidelines.

33
The Whole Family Approach
  • The NHS currently does not commission or provide
    any support for Dads supporting those suffering
    from postnatal depression or for Dads who suffer
    from postnatal depression. Even the new
    specialist commissioning guidelines on perinatal
    mental Health fails to mention any where the role
    dads and partners play.
  •  
  • Following Joes death nobody contacted her
    husband Chris from the Mental Health Crisis Team
    that had been treating her.
  • The clinical records detail how the Crisis Team
    Manger contacted the Health Visitors advising
    them as he has the support of his family DO NOT
    TO MAKE CONTACT FOR 6 TO 8 WEEKS
  • Whilst at the same time the Crisis Team Manager
    discussed ensuring support was provided to
    members of their own teams members and Health
    Visitors staff.
  •  
  • Thankfully the Health Visitors ignored that
    advice and left a hand-written letter offering
    their condolences and telling Chris to contact
    them any time he needed their help or support.
  •  

34
The Whole Family Approach
  • The crucial role carers play, whether dads,
    partners, family members or friends, must be
    recognized by the NHS. Commissioners must ensure
    carers receive the support that they are
    legally entitled, as part of the initial
    treatment of sufferers.
  •  
  • The sad truth is I had to learn for myself,
    without any NHS support, about the significant
    effects on my daughters long-term development
    that are expected as a result of the trauma she
    has already suffered
  •  
  • 12 times more likely to have a statement of
    special needs
  •  
  • More likely to have a diagnosis of depression
    themselves at age 16
  •  
  • I also had to learn of the increased risk she
    will suffer the same sever form of postnatal
    depression as her mum.
  •  
  • Support for those left in tatters after these
    avoidable deaths needs to be dramatically
    improved.
  •  
  • Survivors of Bereavement by Suicide
  • http//www.uk-sobs.org.uk/
  •  

35
The Consequences of Failure
  • The death of Joanne (Joe) Bingley caused horrific
    trauma to her husband, to Joes family and to her
    friends.
  • But also all of those who witnessed Joes body
    being torn apart by the train, her internal
    organs being spread across the tracks, the blood
    pool that resulted and her upper torso being
    dragged along the tracks, until the train came to
    rest. This traumatised
  • The 2 train drivers off work needing treatment
  • The members of public, off work needing
    treatment
  • The 7 year old child waiting on the platform
    needing treatment
  • And all the other people who had to deal with
    the incident
  • All this suffering as a result of the NHS staff
    failing to obtain informed consent, failing to
    provide access to specialist perinatal health
    services and failing to admit Joe to a specialist
    Mother and Baby Unit, even though places were
    available at the time of her death in Leeds,
    Manchester and Nottingham.
  • Following my wifes death I was driven by my own
    grief and the despair. However, at the Coroners
    Inquest the true consequences and costs of the
    failure to prevent what was an avoidable death
    was brought home to me when told of the many
    others affected, including the 7 year old child !
  •  

36
The True Costs of Failure
  • The costs of just one avoidable death like
    Joes would cover the costs of providing all mums
    and dads with the information they require and
    the extra mother and baby unit beds needed.
  • The estimated cost of the emergency response
    (2m) and the economic costs of closing the
    Trans-Peninne train line for several hours
    (20m), hardly feels relevant when compared to
    the widespread human costs.
  • Proper care would have cost
  • 25p for the JBMF information card for mums dads
  • (900,000 25p 176,000 per year for all mums)
  • 5p for the JBMF Severe Postnatal Depression
    checklist/leaflet
  • (22,000 _at_ 5p 1,000 for all sufferers)
  • just 17,000 for the 56 days Joe needed to live!
  •   318 per day for treatment in a Mother and Baby
    Unit Bed
  •  
  • The sad fact is there are approximately 10 to 15
    such avoidable deaths every year costing the
    economy in excess of 300m. not including costs
    of negligence claims!
  •  

37
Mums and Dads at Risk
  • Over 22,000 mothers are placed at risk every year
  • Statistics on postnatal depression show that
  • Based upon 2009 ONS Birth Rates
  • Nationally Yorkshire
  • 1 in 2 mums suffer Baby Blues 353,124 33,179
  • 15 Mums suffer Postnatal Depression 105,937
    9,954
  • 3 suffer Severe Postnatal Depression
    21,187 1,991
  • 1 in 500 suffer Puerperal Psychosis 1,412
    133
  • NICE guidelines specify that those who suffer
    severe postnatal depression should be referred to
    a specialist perinatal psychiatrist
  • less than 37 of PCTs have commissioned
    specialist services.
  • NICE Guidelines state the preferred treatment for
    severe PND or Puerperal Psychosis is
    hospitalisation in Mother and Baby Units (MBUs)
  • only 91 beds exist with places for max 593
    mums
  • 10 Dads suffer Postnatal Depression too

38
Best Practice Treatment
2/3rds of mums suffer from some effects of
depression during or after pregnancy
Peurperal Pscyhosis 1 in 500 Mums
1,412 per annum
Specialist Services Mother Baby
Units Specialist Perinatal Psychiatrists
Severe Postnatal Depression 3 of Mums
21,187 per annum
Integrated Care Networks NHS (Examples
Nottingham, Southampton) Specialist Perinatal
Psychiatric Teams GPs Midwives, Health Visitors,
Care Workers 3rd Sector Support
(Examples) Family Action - support program
befrienders Net Mums - online CBT chat
rooms House of Light - call-line and drop in
groups Joanne Bingley Memorial Foundation -
information, awareness, training education
Mild to Moderate Postnatal Depression 10 to 15
of Mums
84,750 per annum
The Baby Blues 50 of Mums
353,124 per annum
Numbers based on 706,248 live births in 2009 and
the agreed rates of occurence
39
3rd Sector Services
  • Outside of the NHS are a plethora of support
    groups and projects run by 3rd sector
    organisations and self-help providers. These
    provide support and services for mums, fathers
    and families coping with and surviving maternal
    mental illness
  • 3rd Sector Organisations
  • Many charities (Family Action, APNI, JBMF,
    Lighthouse, etc.) provide information and support
    services and conduct local projects.
  • But with no interface into the NHS commissioning
    process these projects can not provide a national
    service and struggle to access long-term funding.
  • Local Support Groups
  • Over 300 known local groups providing support
  • But with little support, supervision or
    co-ordination, often standing alone with no
    interface into any of the Integrated Care
    Networks that should be provided
  • Evaluations of the services provided by local
    support groups have shown them to provide an
    accessible and cost effective service.
  • The Community Health Champions Network
  • A national support network of over 17,000
    Community Volunteer Champions
  • Has been evaluated to show an estimated ROI of
    c112 for every 1 invested.
  • Investment of this type in Maternal Mental
    Health would improve outcomes.

40
The Joanne (Joe) Bingley Memorial Foundation
  • Founders Statement
  • Our Mission
  • How we help

41
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 for severe
postnatal depression she took her own
life.         
The charity 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
42
JBMF - Our Mission
We are here to promote parental mental well
being and to give people help to know the true
joy of a baby in their lives
  • The Vision
  • An integrated national network of support and
    advice services
  • A centre of excellence for Patient Centred
    Support
  • Recognised experts in maternal mental health and
    patient support
  • The Plan
  • Every expecting family to receive z-card Why am
    I not happy?
  • Every dad, family and carer supporting someone
    suffering postnatal illness has a checklist on
    treatment options and where to get support
  • Health and care professionals have access to the
    best training and resources
  • Sufferers of Maternal Mental Illness and Carers
    have a voice recognised by parliament that is
    acted upon
  • Mechanisms and processes are improved so that
    Managers and Directors are held accountable for
    any failure to their patients.

43
JBMF How we help
  • How the foundation delivers its aims
  • Website and information leaflets 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
    support care workers
  • We have supported research including
  • The Patients Association survey of Primary Care
    Trusts
  • Kings College User Group
  • Through the establishment of the Maternal Mental
    Health Alliance we aim to inform parliament and
    NHS policy makers.

44
Maternal Mental Health Alliance
  • MMHA - Our Mission
  • MMHA Who we Are
  • Theory of Change
  • Key Workstreams and Milestones

45
MMHA - Our Mission
The Maternal Mental Health Alliance (MMHA) is a
coalition of UK organisations committed to
improving the mental health and wellbeing of
women and their children in pregnancy and the
first postnatal year.
  • The Vision
  • To improve the lives of mothers and their
    infants
  • The Plan
  • Awareness - to raise awareness of maternal mental
    health problems and the potential effect on the
    physical and mental health of the foetus/child.
  • Education - to increase knowledge and provide
    training in Maternal Mental Health for health and
    social work professionals
  • Action - to campaign for improved and consistent
    Maternal Mental Health care for all women as set
    out in NICE guidance
  • This acknowledges the extensive evidence that
    investing in mental health at an early stage can
    have a dramatic impact on long-term outcomes for
    mothers, fathers, children, families and society.

46
MMHA Who We Are
The Maternal Mental Health Alliance (MMHA) is a
coalition of organisations
Member Organisations
Action for Puerperal Psychosis Netmums
Perinatal arm of the RCPsych Chair of Institute of Health Visitors
Angela Harrison Charitable Trust NSPCC
Best Beginnings Parents 1st
Bipolar UK Patients Association
Bipolar Scotland Perinatal Mental Health Forum Scot
Break the silence - PNI Perinatal Psychological Society
British Psychological Society Postpartum Support International
Centre for Mental Health UK Marcé Society
CYPMH Coalition Rethink Mental Health
Family Action Royal College of GPs
Fatherhood Institute Royal College of Midwives
4children Royal College of Nursing
Homestart Royal College of Psychiatrists
Joanne Bingley Memorial Foundation Tommys the Baby Charity
Marce Society UKIMS
Mental Health Foundation Young Minds
MIND
47
Theory of Change
48
Key Workstreams Milestones
Action
Education
2013
2014
2015
2016
2017
Business As Usual
2018
Awarenes
Applications Tools media based, open access,
self help apps, self referral, map of services,
etc.
Gap Analysis User Needs Services Gaps
Support Groups Coordination, Education,
Information, Supervision, Integrated Care
Networks
User Forums Patients, Carers, etc.
National User Group Alliance
MMH Specialist Commissioning Group
National, Compliant Integrated Care Networks
GP Commissioning Groups
Gap Analysis Best Practice vs Current State
Specialist (Accredited) Resources Health Care
Professionals and Volunteer Support
Education Training Accreditation, Evaluation,
CPD, etc.
Regional Workshops
Feasibility Study
Seminars Conferences
MMHA Website
Applications Tools media based, open access,
self help apps, self referral, map of services,
etc.
Parliamentary Commission
Parliament Launch
Annual Review
Annual Review
Annual Review
Annual Review
Annual Review
Parliamentary Support
MMHA National Campaigns
MMHA Formed
National Awareness Campaigns Integrated Care
Networks
MMHA Member Accreditation
MMHA Core Resources / Funds
Review
Implementation Delivery
Feasibility
Business Case
49
Finally
Charity Registration Number 1141638
50
Why .?
  • Why I am here .
  • Joe was dedicated and caring nursing professional
  • In her 20 years working at Huddersfield Royal
    Infirmary she enjoyed and cherished most of all
    her time mentoring, supporting and training
    others
  • There is a stepped change underway, back to the
    core values of care and patient focus
  • You are as yet un-tainted and unblemished
  • Do not accept from managers, or Directors
  • Guidelines are just guidelines
  • we dont have to follow
  • These things just happen

51
Uncovering the truth
  What I have uncovered during my investigations
and enquiries is both tragic and shocking. It is
my hope and desire that by openly publicising the
horrendous treatment given my wife and I that
people come forward and support my call for the
complete implementation of the policies and
guidelines required to prevent such catastrophic
events happening again. Chris Bingley
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