The call for A Parliamentary Commission into Perinatal Mental Health

Care in the UK

Presented by Chris Bingley

Charity Registration Number: 1141638

JBMF – Founders Statement

“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”

     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. 

        

Parliamentary CommissionInto Perinatal Mental HealthWhere we are at: The requirement for such a commission has been voiced between various MPs and 3rd sector organisations over the last 2 years but taking proposals forward had to wait until the NHS accepted the legal claims regarding the treatment and death of Joanne (Joe) Bingley.

Scope & Proposals Agreed with the Head of Health at Policy Connect

Timeline and Plans Outline agreed with Policy Connect, who will run the Parliamentary Commission

Current Support Various cross-party MPs have agreed their support- including Barry Sheerman, MP for Huddersfield and Char of Policy Connect

A selection of 3rd sector organisations have reviewed plans and agreed their support- using Dads as the link to focus on the impacts felt upon the whole family

Funding £100,000 required, (grants and funding bids in progress)

Next Steps Confirm FundingIdentify Steering Group MembersLaunch of Parliamentary Commission in 2015

Parliamentary CommissionInto Perinatal Mental HealthProposed 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”

Why ….? Joanne (Joe) Bingley

• Joe was a dedicated and caring nursing professional

• Trained initially through Huddersfield Royal Infirmary to qualify as a Registered Nurse, then completed an Honours Degree at Huddersfield University

• She spent 20 years working at Huddersfield Royal Infirmary where she was Sister on day surgery.

• 10 weeks post-partum, whilst being treated at home suffering for severe PND, Joe committed suicide

• 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 ?

Daksha Emson Public EnquiryIn 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 

Confidential Enquiries The Confidential Enquiries into Maternal Death are recognised as

the“gold standard” in in investigating the cause of mums death andthey 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.

Coroners Inquest – Oct 2011The 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 place………informed 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.

Mums continue to die asLessons Learned not ImplementedThe Independent Investigation into Joanne (Joe) Bingley’s 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 TrustFollowing 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, SheffieldTreated at home for severe PND, jumps from John Lewis building in Sheffield•Dec 2013 Roaseanne Hinchlife, Treated at home for puerperal psychosis, sneaks out and Jumps from Cliffs at Whitby

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.

Negligence Claims and NHS Legal Costs (Joe Bingley)In December 2013, nearly 4 years after her death, the Director of Nursing from the NHS trust that treated Joanne (Joe) Bingley finally admitted negligent liability for her death.

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•Joe’s 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 > £1m.

A National ScandalThe death of Joanne (Joe) Bingley highlights a national scandal  •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

Despite Ministerial promises, NHS Service Frameworks, NICE Care Standards and various Guidelines. ………… the NHS has failed to commission Perinatal Mental Health Services across most of the UK.

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

 

Parliamentary CommissionInto Perinatal Mental HealthProposed 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 Dept Health promises after 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 and Significant Others are not being recognised as Carers by NICE even though “Home Care” is the primary treatment offered by Mental Health Crisis Teams 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”

The Joanne (Joe) Bingley Memorial Foundation

Founders Statement How we help Why I am here ……

JBMF – Founders Statement

“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”

     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. 

        

JBMF – How we help

Why I am here ……