Interview: Carol Horn

What is your reaction to the outcome of the inquest?

1. An intolerable burden has been lifted, in that finally we feel our concerns have been heard. A thorough and objective voice has been raised in strong criticism of the catastrophic failings in Powys MH Services.

2. Sadly, this confirmation of our worst fears highlights to us the tragic probability that Sylvan’s death was unnecessary, and had she received the basic medical care she was entitled to, she would be alive today.

3. We must now continue to insist that an in-depth investigation is carried out into possible other failures, so that such dysfunctional senior management as was possibly, or may still remain, in existence, is eradicated.

4. The tone at the top of the organisation sets the tone throughout the organisation, and it is a simplistic and naïve analysis which enables blame to be only directed at the staff at the ‘coal face’ as it were, and to think that, by doing so, the problem has been remedied.

• The inquest found that there were failures in the care system as well as failures by individuals. What lessons do you believe must be learnt from this case and what changes need to be made to mental health services?

1. A disciplinary body is required which can investigate individuals in senior management. It is important that individuals responsible for systems and their adequacy and adequate operation are seen to be accountable to the public, their employers. In the absence of such a disciplinary process, no lessons are learned, and it is at senior levels that the promulgation of better senior management practice and performance will take place throughout Wales.

2. We heard in the Channel 4 programme ‘Dispatches’ how performance and services were improved following adverse incidents, only to worsen a few months later when the pressure was removed and there was no longer a spotlight on the services.

3. Much improved support for the human resources that Mental Health services rely upon, that is ongoing high-quality training in core skills for MH nursing.

4. That no-one, at any level, is in a position again to say ‘I didn’t know/no-one told me’, about practices and performance within services, i.e. robust monitoring and self-assessment. The inquest was remarkable for the catalogue of such phrases being used.

5. That there are in future stringent requirements for good record-keeping and communications throughout the organisation.

6. That managers take pains to satisfy themselves regarding good clinical supervision and appraisals of staff performance and development, in line with fulfilling their own and national targets and priorities.

7. That Mental Health services become pro-active and not just re-active; that a strong element of vigour and alertness is introduced into care systems.

8. It should now be required that ALL health Trusts in Wales put in place high quality mandatory training in suicide awareness and prevention. That all Trusts provide evidence that their MH premises are ligature free.

9. As one HCA remarked in court, ‘It’s common sense, isn’t it?’…. Let’s have a bit more of that.

• Are you satisfied that Powys Local Health Board is doing enough to rectify the situation in mental health wards?

1. How can we say? We have had sight of a lot of documentation and have received many assurances that radical changes are being effected; however, paper and ink are only statements of intention, not proof of implementation and good practice and performance on the wards.

2. It is our belief that it took many years for Mental Health Services at Powys Trust/LHB to reach the nadir it did at Bronllys AMI Unit, and, without robust management, natural entropy will set in again.

3. I cannot speak about anything other than the care Sylvan received and would take pains to say that I am sure there are some stalwart and heroic nurses operating at the establishment. Sadly, Sylvan was only extremely fleetingly in receipt of good nursing and clinical care.

4. We were shocked to hear that what must be deemed core requirements for MH nursing had not been implemented even at the time of Sylvan’s inquest, nearly 3 years later, i.e. good practice in observation, skills and training in suicide prevention and awareness, and an understanding of risk assessment and management by nursing staff.

5. We are shocked to realise it took the Coroner’s recommendation to make this a requirement with the force of law, and therefore more likely to be heeded.

6. What confidence therefore can we have in management capacity to make and maintain radical changes?

7. Little enough has been said yet of senior managers’ particular roles in the catastrophic failings that contributed to Sylvan’s death, and a thorough and independent root cause analysis of the underlying system failures is urgently required.

8. In 2003 the CHI clinical governance review identified many of the failings that were still operating at the time of Sylvan’s death. A number of these failings we hear also played a part in the suicide of another patient just 5 weeks previously to Sylvan.

9. Until such an independent investigation is carried out, we shall not feel enough is being done, as underlying weaknesses may not yet have been identified, thus posing further and ongoing threats to any new systems and changes that may ultimately be put in place.

• How do you think that the Assembly Government should be acting on the outcome of this inquest?

1. I’m as yet unsure what role WAG plays in this. I know that before the implementation of the new LHBs and the particular role of Powys LHB a review of Clinical Governance was also conducted by WAG, possibly as part of the commissioning process. We have not heard whether or not this encompassed MH services, and we have not seen this WAG review.

2. We are however informed by Powys LHB Medical Director that the whole of Mental Health Services transferred en bloc over to the LHB, without benefit of a prior local risk assessment or review.

3. Thus, the ‘new’ managers took over the liabilities of the previous Trust in this respect, with no means of identifying or prioritising current risks to the Mental Health Services as a whole due to lack of Corporate Risk Registers or adequate Clinical Governance systems in place, and hence would have been unable, for example, to adequately plan funding to remedy such risks. This was in our view a foolhardy and dangerous step to have taken.

4. In 2003, at the same time as the formation of the new LHB, the HSE visit revealed other areas of risk within Mental Health Services, and breaches of the H&SAW Act, particularly as regards staff safety, and resulting in the issue of 4 improvement notices.

5. Since the Board was unable to take an overview of the risks due to lack of adequate clinical governance, they acted in the only way they could, addressing what currently was ‘in focus’ and ‘forgetting’ previous high scoring risks to patient safety.

6. The LHB internal report stated itself that, once the HSE notices were issued, the ‘memory of the ligature points issue was gone’. A case of corporate amnesia? In that case, what other memories of other high risks have since ‘gone’ while they have been rushing around putting right the devastating failures revealed by Sylvan’s death?

7. This was no way to manage a high-risk environment, and in any other high-risk industry I am sure corporate licences to operate would have been revoked, pending substantial improvements.

8. We understand that WAG have played a role in supporting/advising Powys LHB in remedying the failures in its MH Services since Sylvan’s death.

9. We are not confident overall that the Assembly Government is acting as robustly as it could regarding mental health, for example:

a. NIMHE published a Suicide Prevention Toolkit in 2003 following on the recommendations of the Safety First report, and I can find no such corresponding document in Wales.

b. Welsh Health Estates did not follow up the recommendations in the Organisation with a Memory and Safety First reports (2000 & 2001), although a very strong letter of guidance by Louis Appleby, Director of Mental Health in England with supporting requirement from Jim Halliwell, Estates Development Advisor in England, were issued immediately in England, to ensure that all ligature points were removed from acute mental health units by March 2002.

c. It is not an equitable situation for patients in Wales, when best practices in patient safety are implemented so slowly.

d. Again, as another instance, the Care Programme Approach has been in operation elsewhere for nearly 15 years, but is still only just being implemented in Wales; at least, it has only just now come into operation in Powys.

e. Where are the teeth in government? Where are the urgent requirements to implement key suicide prevention measures? Where is the Welsh Code of Conduct for NHS Managers?

f. A point I would like to emphasise is that I feel that little recognition is given to the range of mental illnesses. All persons suffering from mental illness, whatever category of illness it is, are cared for in the same ward and by the same nursing staff, without specialisation. The needs of different mental illnesses are different. The care staff is stretched too thin. You do not care for cardiac patients on the same ward as cancer or orthopaedic patients; the nursing staff require specialist skills. Bodily illness is separated into many specialities – mental illness is….just mental illness, no matter what the requirements for care may be, or how conflicting needs deprive certain patients of adequate nursing care.

g. The only resource that MH services ultimately has in the period between admission and effective medication (which appears to be the only clinical intervention practicably available in Powys) is its nursing staff. If this resource is not diligently supported, trained and directed, this tool is worse than useless, it becomes dangerous.

h. Mental health nursing should be re-prioritised with increased available funding, and numbers and quality of staff improved.

i. What hope is there in the current climate of NHS cuts, when we hear of examples (not in Wales) where funding is being diverted at local level in some NHS trusts from Mental Health to cardiac or cancer services?

j. I read with dismay that WAG have required a 10% saving in Mental Health primary care services, in respect of medication and counselling costs. This will self-evidently lead to a decrease in effective care at primary care level. To cut funding here will inevitably deprive the people of Wales, who do or will in future suffer from mental illness, of the little primary care help there is available to them prior to a crisis, and there will either be more deaths in the community or more patients will be admitted as inpatients in emergency, as was Sylvan.

k. It is critical that the Assembly Government recognises that depression is increasing in our society. Severe depression has a 15% risk of death by suicide, higher than all other mental illnesses. More and more young adults are succumbing to this terrible illness. Our young people are the elders of the future, but we are not looking to that future by failing them in times of need.

• It has taken three years for the full facts to emerge, and medical records were withheld by the police for some months. Do you think there needs to be greater transparency in these cases?

1. The ‘full’ facts have not yet emerged!

2. Due to the fact that there was a criminal investigation in progress from the beginning, we were hampered in our ability to communicate with the LHB about the ‘facts’ of Sylvan’s death, due to ‘sub judice’ issues.

3. However, there were many other less sensitive areas for communication. We felt that we were dealt with extremely badly by the LHB on the following issues (which we can substantiate):

a. It took 6 months to obtain an assurance from the LHB that the complaint of a very general nature we had made was in fact a valid complaint, even though we were in no position to detail this complaint due to our ignorance of the ‘facts’. During these 6 months we were passed between 5 members of staff acting as ‘complaints managers’.

b. The Consultant Psychiatrist responsible for Sylvan’s care did not, at any time, contact any member of our family following Sylvan’s death, to communicate his condolences or in any way speak to us about her, although his responsibility as her consultant was to do just that.

c. At no point during the next 3 years did the LHB initiate contact with Sylvan’s partner, myself or Sylvan’s father, e.g. the first official correspondence of condolence I received as Sylvan’s mother came 6 weeks after her death and after I had made several phone calls to the LHB to find out what was happening!

d. Because we were restrained from talking to the LHB about the ‘facts’ in Sylvan’s death, we proceeded in JUNE 04 to maintain contact by requesting other information to help us understand the environment and systems operating in the NHS, such as policies, procedures, protocols and other documentation . Despite many offers of help and support it took another 6 months, and a strong complaint to the Chief Executive and other Executive Officers before we finally obtained any documentation at END DEC 04.

e. At END MAY 04 we asked to be kept informed about the progress, and procedures used to conduct, internal investigations; after another strong complaint to the Chief Executive, he wrote with this information on NOVEMBER 1st 2004 (another delay of 6 months), and we learnt that due to legal constraints the internal report would not even then be released to us;

f. the first we heard about the 4 dismissals of staff was from the BBC – the LHB did not take it upon themselves to let us know before the media learnt of it;

g. we were then informed by letter at the beginning of NOVEMBER 2004 that ‘further disciplinary processes’ were ongoing and we followed this up, since we had heard nothing more, in JUNE 2005. In MID DECEMBER 2005 (another delay of 6 months), the Chief Executive finally responded, at our insistence, by stating that there were no ongoing disciplinary procedures and the LHB solicitors had advised that they could not answer this question due to the ongoing nature of the criminal investigation. To this date, we have not learnt what these other further and ongoing disciplinary processes were, or their outcomes.

• Do you feel that you were kept in the dark or had to push to discover the truth?

1. My barrister and solicitor stated after the inquest that without our tireless efforts to exhaustively research and benchmark and keep asking questions over the nearly 3 years since Sylvan’s death there may not have been an Article 2 inquest, of 3 weeks duration, and the outcome may have been very different.

2. These efforts involved pushing for the truth and good treatment from all the organisations that were involved in the matter, and included:

a. insisting on adequate police liaison commensurate with the ACPO Family Liaison Manual. This required a complaint to the Chief Constable of Powys Dyfed Police, and was withdrawn completely during later stages of the investigation;

b. we were advised and supported by a London-based charity involved in Work-Related Death Advice (Centre for Corporate Accountability) and they accompanied us to all meetings with police and CPS – they have been and continue to be absolutely invaluable and a source of strength when we nearly succumbed, we cannot praise them highly enough;

c. we strongly requested that the police resume their investigation in November 2004 by scrutinising management involvement in the LHB failings after the staff dismissals; we felt that such an unprecedented outcome must have been a strong indicator of gross management failures, and this was agreed to.

d. It took a further 14 months of what I will now describe as desultory further investigation followed by the CPS final decision in January 2006.

e. Their decision was insufficiently robust in our opinion, and left us feeling that there were remaining issues that had only been cursorily pursued, and yet others about which we felt we were even being misled.

f. This has subsequently been proved correct during the Inquest testimony, when the detective constable in court admitted that some of the crucial ‘evidence’ used by the CPS to come to their decision was merely ‘hypotheses’ on the part of the police, with no basis in fact!

g. We could not afford to mount a Judicial Review of the CPS decision although advised that we had legal grounds on which to do so.

h. The police never took a statement from the previous General Manager of MH Services who was employed in Powys up to 3 weeks before Sylvan’s death. It was only at Inquest stage that we as Sylvan’s family requested he be a witness; likewise the administrative clerk who senior managers blamed for faulty procedures in distributing vital hazard notices and thus for their remissness in addressing the issue of ligature points.

i. We also requested disclosure of emails and other documentation that by then we knew had to exist.

j. In summary, I can say with feeling that there are still issues about which we feel no nearer to the truth. In particular the management’s accountability and responsibility.

k. At some point we shall feel that we can let go and accept that we cannot know everything. But it is not yet.

• Regarding Sylvan’s treatment before she was admitted to Bronllys Hospital: were you satisfied with it, and do you think her condition was taken seriously? Do you think that more could have been done to prevent Sylvan from reaching crisis point?

1. Undoubtedly. What Sylvan needed was skilful and rapid intervention by sympathetic and supportive human beings. Her decline was inexorable. Her partner was ignored and marginalised throughout. He was not asked for information or given the opportunity to describe what was happening for him as Sylvan’s carer at home, and thus receive support himself as her carer. Both Sylvan and Dave were out of their depth.

2. There was inadequate skill and care at primary level and no appreciation of the urgency of the situation. Provision of daily home visits would have helped. Provision of prompt and effective counselling would have helped. An urgent referral for professional psychiatric opinion would have helped.

3. Throughout Sylvan’s path to secure professional understanding and help, she met very little sympathetic and human understanding and intervention. To such an extent that we all felt that it took Sylvan to have to attempt suicide twice before she was taken seriously.

4. Well meaning people, including those who should know better, are inclined to say that there is nothing you can do to stop someone from dying who is determined to do so; that this is, in some way, their choice. We refute this absolutely. They do not wake up one morning and decide they must die – it takes months. And there is no choice when a person is critically depressed – death seems to be the only way out. Insight is lost.

5. There should also be a highly visible public campaign to raise the general public’s awareness of the problem, to remove the stigma and shame that prevents many people from requesting help.

6. I cannot urge enough my opinion that therapeutic care rests on the twin pillars of skills and the ability to care as a human being.

7. I wonder if this latter quality can be trained into a person, be they doctor or nurse? But without this, the therapeutic process, especially for those with mental illness, is a cold and lonely road, and probably does not deserve the adjective ‘therapeutic’.

• The Health & Safety Executive will take up an investigation regarding possible breaches of the Health and Safety at Work Act following the inquest. Do you plan to continue to fight for justice or campaign for better services?

1. We shall continue to involve ourselves as closely as possible in the progress of the HSE investigation.

2. And we shall actively campaign for better MH services, although it is impossible to say precisely how we will decide to pursue this at this juncture.

3. There is a balance to be struck, and I feel that there are now things I want and need to do in my life for myself personally.

4. We must wait until the CPS yield primacy in the investigation to the HSE.

5. We must wait for the final internal report from the LHB. Hopefully this will be a high priority and as prompt as possible, and we will be the first to receive copies.

6. While the recommendations of the Coroner wait in the wings, more and more potentially suicidal people may enter the doors of Bronllys AMI Unit.