The Triangle of Care™¹ is not a difficult concept – it’s just common sense. Yet how many Mental Health & Learning Disability Consultants and other clinicians ignore it?
We reported the Inquest into Ellie Brabant’s death just three months ago. Yet this month, we attended the Inquest into Maria (‘Joey’) Duarte’s death. She died at the same Southern Health NHS Foundation Trust unit (Antelope House) just 2.5 months after Ellie.
Ellie and Joey had two things in common – extremely supportive families – and the same Consultant Psychiatrist, Dr Obed Bekoe. Yet were the families involved in their care?
NO! Dr Bekoe admitted he had not engaged with Joey’s family because he felt she had capacity and she had not requested it.
Dr Bekoe: As a Consultant Psychiatrist, an Expert Witness, an RCPsych Examiner, an Educational Supervisor and a Medical Appraiser, exactly what part of the Triangle of Care™ do you not understand?
Patients don’t have to ask about family engagement: they should be offered it. Capacity in a patient with suicidal thoughts should not be assumed.
Best practice is clear and unequivocal:
“In line with good practice, practitioners should routinely confirm with people whether and how they wish their family and friends to be involved in their care generally, and when looking at information sharing and risk in particular.”²
In short, a patient’s capacity is irrelevant – clinicians should discuss family engagement with patients routinely – not wait for patients to ask. Even in respect of capacity, good practice suggests:
“If a person is at imminent risk of suicide there may well be sufficient doubts about their mental capacity at that time.”²
Is this not common sense too? In CRASH’s opinion, for example, there must be doubts about the capacity of anyone, who sits on a railway bridge for five hours threatening to throw himself off – much less a person known to be mentally unwell. Yet, another Southern Health Consultant Psychiatrist thinks not.
Unrelated directly to The Triangle of Care™, the Department of Health, Royal College of Psychiatrists and others issued a ‘Consensus Statement‘ in January 2014 as part of the suicide prevention strategy for England. It aimed (inter alia) to improve information and support for families concerned about a relative, who may be at risk of suicide.
The General Medical Council, Nursing and Midwifery Council and Health and Care Professions Council confirmed that the advice and policies set out in the Statement are consistent with their guidance on consent. The Information Commissioner’s Office confirmed that it is consistent with the Data Sharing Code of Practice. Read more→
So why, five years later, are some Members of the Royal College of Psychiatrists not compliant with good practice in this respect and why did Southern Health only learn about it in 2019?
There were multiple other similarities between Ellie and Joey’s deaths, for example:
- The same Responsible Clinician, Dr Obed Bekoe.
- Total failure to work with a very supportive family.
- Identical ligature point – top of a door.
- Similar ligatures – clothes.
- Observations, when expressing suicidal thoughts, too infrequent and carried out by junior staff.
- Allowed leave from Antelope House despite concerns about their well-being. (Joey was a voluntary patient but could have been sectioned.)
- Both passed like parcels between various Southern Health Teams and multiple Responsible Clinicians without proper handovers/communication/care plans/risk assessments.
- Questions about medication.
- Failure on at least one occasion to record suicidal thoughts.
There were a couple of common problems indentified at the Inquest:
- Junior staff blamed rather than senior staff taking personal responsibility (with the honourable exception of the male senior nurse, who gave evidence in person).
- A page from shift handover notes missing from Coroner’s bundle – revealed by the senior nurse. Yet again Southern Health lacks diligence in preparing Inquest documentation … and yet again the moment passes without any consequences for them. A deliberate act or simply incompetence?
In short, total failure in clinical management, family engagement and Inquest preparation.
On a positive note, Southern Health officers and staff were soberly dressed and conducted themselves appropriately at Joey’s Inquest. There was no laughing and joking as witnessed at Ellie’s Inquest.
Lynne Hunt, Chair of South Health’s Board of Directors, said:
“Our own investigations and the coroner’s conclusions revealed missed opportunities. Joey’s death has led to meaningful and ongoing changes to make Antelope House, and indeed all our whole trust, a safer place.”
All good stuff (and some improvements were not ‘quick fixes’) but Joey’s family could well ask:
“What steps were taken to implement the simpler improvements, which were clearly required immediately after Ellie Brabant’s death?
“The Board did not report any of the clinicians involved in Ellie’s death to their regulators? Will the Trust report those involved in both deaths to regulators or – failing that – will they be disciplined internally, retrained and supervised?
Elsewhere, Greater Manchester Mental Health NHS Foundation Trust received a second gold star for its commitment to the national Triangle of Care™ initiative. (Alarmingly at the time, only one of four mental health trusts in the country to do so.)
West London Mental Health NHS Trust committed to putting it in place during 2018.
And finally, on the website of Kent and Medway NHS and Social Care Partnership Trust:
“The Triangle of Care™ guide was launched in July 2010 by The Princess Royal Trust for Carers (now Carers Trust) and the National Mental Health Development Unit to highlight the need for better involvement of carers and families in the care planning and treatment of people with mental ill health.”
To paraphrase the Princess Royal herself, after nine naffing years the Triangle of Care™ is still not in place at Southern Health or nationally and after naffing five years, Consultants are not compliant with good practice set out in the Consensus Statement.
And here’s a couple of images found on the website of Avon & Wiltshire Mental Health NHS Partnership NHS Trust – awarded a second star in 2015:
When will Southern Health NHS Foundation Trust achieve similar recognition?