Suicide Risk Assessment Tools in the NHS

Kevin Hollinrake Excerpts

Wednesday 4th September 2019 Westminster Hall

[Kevin Hollinrake (Thirsk and Malton) (Con)]

I beg to move,

That this House has considered the use of suicide risk assessment tools in the NHS.

It is a pleasure to serve under your chairmanship, Sir Christopher.

According to a detailed study carried out by Manchester University, in one year alone 636 people who were deemed by clinicians to be at low or no immediate risk of suicide went on to take their lives within the next three months. Of course, 636 is just a fleeting fact, one of myriad statistics about the NHS that we can cite every minute of the day, but every one of those 636 deaths is a tragedy—it is a brother, a friend, a partner, a child. One of those 636 people whose lives were lost in that year was the son of two of my constituents, a young man called Andrew Bellerby.

It may break the heart of any parent in this Chamber to see this photograph of young Andrew in his blazer as he went to school some years earlier. As one who proudly took my own children to their new school only this week, it is shocking to think that at some point one might lose one’s child in such circumstances. On 10 July 2015, many years after the photograph was taken, and in the same year as the study that I just mentioned, Andrew took his own life. The loss of Andrew’s life and the devastating impact that it had on his loved ones was, in all likelihood, totally needless. According to an expert witness who represented the Bellerby family, on a balance of probabilities Andrew would be alive today had the NHS trust that was entrusted with his care looked after him properly.

At this point, I would like to play tribute to Andrew’s family, particularly his father, Richard Bellerby. I understand that Richard’s brother is with us today in the Public Gallery; Richard could not be here himself, but I think that he is watching this debate via a parliamentary link. It was only due to his tireless efforts, his determination and his commitment to make sure that others do not suffer the same fate that we are debating this issue today.

Not only did the Bellerby family have to cope with unimaginable grief and loss, but they then had to fight a two-year battle with the Sheffield Health and Social Care NHS Foundation Trust to establish the truth. The truth, which the trust finally and begrudgingly apologised for, was that there had been a simple but fatal series of errors. Andrew’s state of mind was assessed by untrained nurses using an assessment tool—a checklist, for want of a better word—that was not fit for purpose. As a direct consequence, they made an incorrect diagnosis, without even taking into account his past behaviour.

[Jim Shannon (Strangford) (DUP)]

First of all, I congratulate the hon. Gentleman on bringing this matter forward. In Northern Ireland, the figure for suicide is 20% higher than for the rest of the United Kingdom. Does he agree that it has come to the point that all frontline medical staff, from pharmacists to treatment room nurses, should be trained in appropriate suicide risk assessment, especially taking into consideration the high rate of suicide across the whole of the United Kingdom, and in particular in Northern Ireland?

[Kevin Hollinrake]

The hon. Gentleman is absolutely right. That is one key component of three: training nurses; using a proper, validated tool; and taking into account the past behaviour of the individual and the context of the situation. None of those three things was in place for Andrew. As a consequence, 48 hours after being admitted to hospital in an ambulance, Andrew took his own life.

[Liz Twist (Blaydon) (Lab)]

Will the hon. Gentleman give way?

[Kevin Hollinrake]

I am happy to give way to the chair of the all-party parliamentary group on suicide and self-harm prevention.

[Liz Twist]

The hon. Gentleman is raising a very serious issue. I am grateful to Samaritans for a briefing on it ahead of this debate. It is absolutely clear that these risk assessment tools are not in themselves complete. They must be supported by consideration of the context, including previous history, and by a professional assessment of what is happening. Does he agree that it is absolutely essential that all trusts ensure that that happens?

[Kevin Hollinrake]

I entirely agree with the hon. Lady. I know that the Bellerby family would very much like to meet the Minister here today—the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Mid Bedfordshire (Ms Dorries)—to see what can be done to make sure these situations do not happen again, and I think they would be very pleased to meet the hon. Lady, too, because I know that she does tremendous work in the all-party parliamentary group.

[Hugh Gaffney (Coatbridge, Chryston and Bellshill) (Lab)]

Will the hon. Gentleman give way?

[Kevin Hollinrake]

I am happy to give way again and then I will make some progress.

[Hugh Gaffney]

I will just add my point, from Scotland. In emergency departments, the staff have not been trained up to the level that we are hearing about today. Suicide is a big risk, especially among young people, and all we are asking for is that people look at this situation and give emergency staff the proper tools and training. If that had happened before, Andrew would be with us today.

[Kevin Hollinrake]

The hon. Gentleman is absolutely right and I am grateful to him for his very kind contribution. I know that Andrew’s family will also be grateful to him.

The fact is that the Sheffield trust had been treating Andrew for many years; it knew him well and knew that he was a serious suicide risk, yet none of this was taken into account when he was admitted to hospital for that fateful final time. The untrained nurses carried out the assessment using a crisis triage rating scale, CTRS, and deemed Andrew fit to be discharged. They rated Andrew 14 on a scale of zero to 15, where 15 means that there is no serious or immediate risk of suicide, despite the fact that Andrew had a history of suicide attempts and also threatened to jump out of a fifth floor window while he was being assessed.

The insult to fatal injury in this case is that Mr Richard Bellerby has had to fight for justice and answers for years. He describes the trust’s role in this process as a campaign of dirty tricks—dirty tricks, denial and deceit. In February 2018, the trust finally admitted its wrongdoing, apologised and agreed to settle out of court, but before doing so it had persistently and gratuitously maintained that it was not at fault. For instance, the trust had said that it had an expert witness whose opinion was that whatever the trust would or could have done, Andrew would still have taken his own life. However, the trust refused to supply that expert witness’s evidence and it appears that such an expert never even existed.

The inquest established that the trust was guilty of missing numerous opportunities to provide help. The trust’s own internal investigation revealed that the nurses who had seen Andrew had no training in this area, which directly contravenes national guidelines. At the inquest, there was an embarrassing blame game between Andrew’s GP and the trust, with each pointing the finger at the other. As Mr Bellerby has said, it was like musicians in an orchestra playing from a different sheet of music, with no conductor.

There appears to be a complete lack of accountability; nobody has been properly held to account for these errors. The trust admitted in its internal investigation that it had failed to carry out adequate risk assessments. In Richard Bellerby’s profession, which is construction, failure to carry out proper risk assessment or failure to train people properly can lead to a charge of criminal responsibility for manslaughter in the event of a fatality.

Instead of being open and honest about the circumstances surrounding Andrew’s death, the trust only corresponded when it was forced do so. There were no responses to Mr Bellerby’s letters unless they were sent by recorded delivery, and even then the only responses came from corporate affairs managers rather than from clinicians, and they still failed to provide answers. The trust has not even responded to my letters, other than to send a holding response. I wrote to the trust on 28 January asking for answers to questions and I chased things up on 6 March, but there was still no full response. When the trust finally agreed to meet Andrew’s father, Mr Bellerby, it was of course a meeting with the corporate affairs director. When Mr Bellerby insisted on a clinician being present, the meeting was cancelled.

The trust refused simple requests for information, such as how long the nurses who saw Andrew had worked at the trust and what their qualifications were. The two-year battle cost the NHS around £40,000 just to reimburse the Bellerby family’s legal costs, in addition to any costs that the trust itself and NHS Resolution would have incurred. The total bill is likely to be in excess of £100,000—all for £9,000 in compensation. Critically, there was no compassion, no condolences and no remorse. Instead, there was contempt, denial and disregard.

To say the Bellerby family won is a travesty. They lost their son, a grandson, a brother, but they did defeat the trust. With the help of their solicitors, Irwin Mitchell, whose efforts were instrumental to their success, they won their case, they received their grudging apology and the trust has now stopped using the CTRS. All the family wanted was recognition of the failures and an apology. Given that, everything could have been sorted on day one. Instead the family had to fight against our own bureaucracy. It beggars belief that we tolerate a system that behaves in this manner.

Surprisingly, given the facts of the case and its role in the two-year cover-up of the truth, NHS Resolutions agrees with having a position of openness. In its 2018 report, “Learning from suicide-related claims”, it states:

“Where compensation is due it should be given willingly and in a timely manner to prevent further distress and suffering to distraught families.”

It is time we lived up to those fine words.

The Bellerby family have worked closely with Manchester University on the inquiry I mentioned earlier, which is called, “The assessment of clinical risk in mental health services”. It has helped to establish the extent of the problem of inappropriate use of suicide risk assessment tools in the NHS and the figure of 636 deaths per annum. It has also established that today, 33 out of 85 trusts use a tool that has not been independently validated and 29% of trusts use it with untrained staff. The national inquiry into safety in mental health recently raised issues of the

“inconsistency across mental health trusts in the length and content of risk assessment tools”

and a

“variation in how tools are used and examples of use contrary to national guidelines”.

Everyone seems to agree that the incorrect use of such tools is wholly wrong. Mental health charity Mind is clear that the Government should standardise tools across the service, improve training and support in their usage and follow-up within 48 hours with those who have received assessments. The Royal College of Psychiatrists said that we should

“move away from a risk assessment model to a risk reduction model”.

I know the Minister will be appalled by the full details of the case and will be determined to help drive change in the system, and I have some questions for her. What has changed since Andrew’s death? Specifically, what action will she take to ensure that mental health trusts are only using risk assessment tools that have been independently validated as safe? What action is she taking to ensure that staff in mental health services receive training in risk assessment? What action is being taken to support staff to be able to talk to people about suicidal thoughts? Will she implement a process so that the Care Quality Commission or another body can check that best practice is adopted? Will she commit to an ambition for zero suicides among all those under the care of mental health services? Will she look at the behaviour of the trust and drive through a new policy of openness and honesty in our health services? Finally, will she meet me and my constituents to hear Andrew’s story and possible solutions at first hand, to ensure that Andrew did not die in vain?

--- Later in debate ---

[Ms Dorries]

I am afraid I must disappoint the hon. Gentleman. This is my third day in, and I have not yet had a chance to discuss Northern Ireland in detail, but as a result of his intervention I will ensure that we do that, and it will be on tomorrow’s agenda.

The letter that NHS England sent out highlights the report from the University of Manchester on “The assessment of clinical risk in mental health services”, and asks trusts to ensure that their risk assessment policies reflect the latest evidence from the university, as well as best practice. I am pleased that NHS England and NHS Improvement have committed to working with trusts to improve risk assessment and safety planning as part of future quality and safety work on crisis care and suicide prevention.

My hon. Friend the Member for Thirsk and Malton asked specifically about the role of the Care Quality Commission in ensuring that trusts are adopting best practice in respect of risk management processes. The CQC has assured me that risk management processes are a key feature of every CQC inspection. I hope that that assurance from the CQC, along with the letter that NHS England sent out this week, will go some way to reassure my hon. Friend.

[Kevin Hollinrake]

I am sure that the work that the Minister has already done to raise the issue with trusts is very positive news for the family. On the basis that people do not do what is expected but what is inspected, it is good to hear that some processes are already in place in the CQC. Will new processes be added? Presumably checks were happening when the situation occurred, so we need something else to ensure that best practice is properly adopted.

[Ms Dorries]

If I may continue my speech, I hope that I can reassure my hon. Friend on that point.

The Government are committed to a culture of openness, honesty and transparency in the NHS. The legal duty of candour means that trusts need to be open and transparent with patients or their families when something appears to have caused, or could lead to, significant harm. Trusts could face action from the CQC if they are seen to be failing to comply with that duty. I think that some good news will come out later in the year that will hopefully reassure my hon. Friend regarding a new culture that will develop within the NHS to encourage staff and clinicians to be more open about incidents as they happen, so that they share information and we can learn from such incidents.

Our national learning from deaths policy has introduced a more standardised approach to the way that trusts review, investigate and learn from deaths. The national guidance on learning from deaths, published in 2017, is about supporting trusts to become more willing to admit to and learn from mistakes, so that they reduce risks to future patients and prevent tragedies from happening in the first place. The guidance is clear that trusts must engage meaningfully and sensitively with bereaved families and carers as part of that process. I hope that, as a result of those measures, what the Bellerby family went through in 2015 will never be experienced by another family. To support our national policy, the CQC has strengthened its assessment of learning from deaths by trusts.

I will talk about what we are doing to reduce suicides across the NHS more widely. People in contact with mental health services account for around a third of all suicides in England, and arguably some of the more preventable ones. The overall suicide rate among people in contact with mental health services has reduced significantly over the last decade, but numbers remain too high. We must not lose sight of the fact that nobody under the care of NHS services should ever lose their life as a result of suicide. At the start of 2018, we therefore launched a zero suicide ambition, starting with mental health in-patients, but asking the NHS to be more ambitious and look to expand it to include all mental health patients.