Joanne

1
Joannes Story A Reason to ActWhats Going
Wrong ? Presented by Chris Bingley
Charity Registration Number 1141638
2
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
3
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
•  

4
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.

5
Joes Pathway to Despair ...1 of 3

• Pre-Natal Previous termination, miscarriages and
  treatment for depression in documented in Health
  Visitor records BUT NONE of the 5 mental health
  risk assessments completed, as described in the
  Kirklees Maternal Mental Health Care Pathway as
  the responsibility of Health Visitors, a breach
  of care quality standards and safe systems of
  work.
• 18 Feb 2010 Emily Jane Bingley Born after 5 days
  in labour
• 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

6
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. 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 substantiates 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. and Joe left the
  session in frustration (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 even
  though she admitted to recognising a break-down
  in Joes relationship with her husband.
• Whilst sat in her car ready to leave, the
  husband (Chris) 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!

7
Joes Pathway to Despair 3 of 3

• 29th April
• AM visit by Mental Health Crisis Team Dr and
  Nurse 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
• PM visit by Health Visitors - 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 when told Crisis Team is planning to stop
  providing support, and HV contacts her manager to
  log risks.
• No-one contacts Husband (The Carer) to discuss
  risks, inquire of patients state or to check if
  he the carer is able to cope prior to the Bank
  Holiday weekend.
• 30th April 2010 - Joanne walks on railway
  tracks, throwing herself under a train
• 4th May 2010 - On her first day back at work
  following Bank Holiday, 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.

8
NHS Responses after Joe died

• Huddersfield Royal Infirmary
• - Excess stamp duty to pay for
• - Letter of condolences and apology for your
  loss
• Mental Health Crisis Team Admin Dept
• - Request to compete Patient Satisfaction
  Questionaire
• - Reminder to complete Patient Satisfaction
  Questionaire
• Mental Health Crisis Team Manager - in a
  discussion recorded by Health Visitors
• Patients husband has family support so do not
  contact for 6 to 8 weeks
• Support for Crisis Team staff and HV staff
  affected by Joes death 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 their
  investigating Joes death

9
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

10
The Independent Investigation

• Due to time constraints placed upon the
  investigation by the NHS it was agreed
• The investigation team was only able to review
  the clinical documentation, policy documents and
  staff written statements and records, without the
  benefit of investigators interviewing staff.
• As the NHS were unable to identify investigators
  in Midwifery or Health Visiting, these areas were
  supposed to be reviewed and investigated at a
  later stage.
• 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
• 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

11
Results of Previous Investigations
19 Previous Independent Investigations conducted
by the Yorkshire and Humber Strategic Health
Authority are available to the public. These show
recurring failures in the treatment and care of
patients and Carers consistent with Joanne
Bingley.
12
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
  placeinformed 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.

13
Negligence Claims (Joe Bingley)and NHS Legal
Costs

• In December 2013, a little under 4 years after
  her death, the Director of Nursing from the NHS
  trust that treated Joanne (Joe) Bingley finally
  admitted fault.
• 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
• Joes 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 gt 1m.

14
Mums continue to die asLessons Learned not
Implemented

• The Independent Investigation into Joanne (Joe)
  Bingleys 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,

15
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.

16
The Francis Enquiry

• For the NHS to place the quality of patient
  care, especially patient safety, above all other
  aims we must have candour when mistakes happen
  and acknowledge all medical errors.
• Only 24 per cent of the 140 possible contributory
  factors identified by the inquiry team had been
  identified in local investigations at the time of
  the incidents.
• So 76 per cent of the learning from the incidents
  had been missed a situation that there is an
  urgent need to improve.
•  
• As well as the new statutory duty of candour,
  greater use will be made of incident data,
  including a commitment for CQC to consider each
  hospitals review of serious untoward incidents
  as part of its pre-inspection activity.
• NHS England is to launch a program of new patient
  safety collaboratives, which will be expected to
  provide expertise on learning from mistakes and
  help to provide a rigorous approach to
  transforming patient safety.
•  
•  
•  
•  

17
The Consequences of Failure

• The death of Joanne (Joe) Bingley caused horrific
  trauma to her husband, to Joes family and to her
  friends. But it also had a significant impact on
  the lives of many others.
• Following his wifes death Chris was driven by
  his own grief and the despair to find out answers
  to his questions . Why?
• At the Coroners Inquest the true consequences
  and costs of the failure to prevent what was an
  avoidable death was brought home to him when
  told of the many others affected, including the 7
  year old child who witnessed Joes death !
• Many 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. were
  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 to
  go to school
• And many 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.
•  

18
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 15p for the JBMF information card
for mums dads (900,000 25p 176,000 per
year for all mums) 2p for the JBMF Severe
Postnatal Depression checklist/leaflet (22,000 _at_
5p 1,000 for all sufferers) just 17,000
for the 56 days treatment Joe needed to live!
318 per day for treatment in a Mother and Baby
Unit Bed   The sad fact is each year there are up
to 66 maternal suicides due to psychiatric causes
of which 86 are Avoidable Deaths (diagnosis
and treatment was possible). A single Avoidable
Death such as Joanne Bingley can cost the
economy in excess of 22m and can cost the NHS
over millions in legal fees defending for years
the negligence claims, irrespective of any payout
after finally admitting to a breach in duty of
care.      
19
A National Scandal

• The death of Joanne (Joe) Bingley highlights a
  national scandal
• Despite Ministerial promises, NHS Service
  Frameworks, NICE Care Standards and various
  Guidelines. the NHS failed to commission
  Perinatal Mental Health Services across most of
  the UK.
•  
• 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

20
Mums and Dads at Risk

• Statistics on postnatal depression show that
• 2/3rds of mums will suffer a mood disorder during
  or after pregnancy
• Based upon 201 ONS Birth Rates
• UK East Midlands
• 1 in 2 mums suffer Baby Blues 403,888 27,689
• 15 Mums suffer Postnatal Depression 121,166
  8,307
• 3 Mums suffer Severe Postnatal Depression
  24,233 1,661
• 1 in 500 Mums suffer Puerperal Psychosis
  1,616 111
• Maternal OCD
• Maternal PTSD
• 10 Dads who suffer from PND without treatment
  80,778 5,538
• 50 Mums suffering in silence too afraid to seek
  help 60,583 4,153
• 35,000 mums suffering in silence every year too
  scared to seek help (i.e. half of all mums
  affected by mild to moderate postnatal
  depression).
•  

21
Best Practice Care Standards
National Perinatal Mental Health Project Report
A Review of Current Provision (2011)
Peurperal Pscyhosis 1 in 500 Mums
Specialist Perinatal Mental Health
Services Mother Baby Units Specialist Perinatal
Psychiatrists Non - Specialist (PNMH) Services
Admittance to general psychiatric ward Crisis
Home Resolution Teams gatekeepers
1,412 per annum
Severe Postnatal Depression 3 of Mums
21,187 per annum
Mild to Moderate Postnatal Depression 10 to 15
of Mums
NHS Integrated Care Networks (Examples) Nottingham
, Southampton, Birmingham, Glasgow,
etc. Non-specialist services - lead by PNMH
Champions with support of GPs, Midwives, Health
Visitors, Care Workers, volunteers, etc. 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
- raising awareness, training education
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
22
Dads and Significant Others

• Whilst Health Visitors and Midwives are the
  primary contact for Mums during pregnancy latest
  research shows mums are far more likely to turn
  to their partners for help and support than to
  Health Care professionals.
• A survey by Netmums and the Royal College of
  Midwives (Nov 2012) found
•  
• Mums mainly (42) turned to their husband or
  partner when they first talked about how they
  felt with only a third (30) first mentioned it
  to a health professional.
•  
• Only a third of mums (30) were told about the
  possibility of depression by their midwife and
  only a quarter ((27) reported being asked how
  they felt emotionally during their pregnancy.
• Nearly three-quarters (74) of those surveyed
  said it often took a few weeks or more likely a
  few months before they recognised they had a
  problem. 
•  
• Over a third of women who suffer depression
  during pregnancy have suicidal thoughts.
• The NHS currently does not commission or provide
  any support for Dads, family members or
  Significant Others who are expected to provide
  the support to those suffering from postnatal
  depression as insufficient research has been
  done!
•  

23
Dads as Carers

• The NHS Choices Website gives as an example a a
  Carer is someone looking after a person between
  mental health crisis.
• "As a new father, it was very difficult. It was
  time for me to learn everything.
• It's expected that 'you are the man' so you can
  manage.
• It's never about how you are feeling, it was all
  about her.
• It didn't matter what you did, nothing was good
  enough.
•  
• There was the new baby, we had a new house and
  all the added other pressures that Michelle use
  to deal with and, most importantly, my wife's
  illness. I had to give up work for six months.
•  
• The isolation was the biggest thing I felt hard
  to cope with. How was I going to tell my friends
  if I didn't understand myself?
• I was exactly like the people who still say "how
  can you be depressed" - with mental illness, you
  can't just snap out of it. Mark Williams
• www.fathersreacingout.com Fathers Reaching Out
  aims to help men who suffer from perinatal mental
  illness and who are left responsible for caring
  for mums suffering from perinatal mental illness
• The crucial role Carers play, whether dads,
  partners, family members or friends, must be
  recognized by service providers even though
  NICE fails to mention DADS

24
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
•  

25
Why I am here .

• Why ?
• Joe was a dedicated and caring nursing
  professional
• In 20 years working at Huddersfield Royal
  Infirmary she enjoyed caring and treating those
  who were ill but also cherished her time
  mentoring and supporting others
• Whilst there is a stepped change underway, back
  to the core values of caring and putting the
  patient first
• It will take at least 10 years before significant
  improvements are seen in the provision of
  Specialist Perinatal Mental Health Services
• The 3rd Sector, Family and Mental Health Services
  must work together to create the
  Integrated Care Networks required to fill the
  gaps in mental health care, provide support for
  those suffering in silence and eliminate the
  unnecessary suffering and prevent the avoidable
  deaths that devastate the whole family.

26
The Joanne (Joe) Bingley Memorial Foundation

• Founders Statement
• How we help
• Parliamentary Commission into PNMH
• Why I am here

27
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
28
JBMF How we help

• How the foundation delivers its 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 MPs 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.

29
Parliamentary CommissionInto 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

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Why I am here
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Why I am here