Bet­ter men­tal health care

Sunday Sun - - News -

Chris Tasker says he is sat­is­fied with the con­clu­sion of Rachel’s in­quest the house for four years and shut out the peo­ple she loved the most.

Mr Tasker said: “Rachel did love peo­ple but she found it dif­fi­cult to re­late to oth­ers and I know she was frus­trated by that.”

It was only later in her life that she was di­ag­nosed with an autism spec­trum dis­or­der.

Dur­ing the in­quest into the cir­cum­stances sur­round­ing Ms Tasker’s death at New­cas­tle Coro­ner’s Court, a num­ber of “in­ad­e­quate” fea­tures about her care were iden­ti­fied.

The “care plan” drawn up by SLAM

doc­tors for her tem­po­rary stay in New­cas­tle “did not iden­tify any sup­port for her while on leave or con­tin­gency plans should the leave break down or should Rachel refuse to re­turn from leave”, the in­quest heard.

Coro­ner Karen Dilks also sin­gled out SLAM’s fail­ure to agree the care plan with men­tal health spe­cial­ists in the North East as an­other cru­cial short­com­ing.

Af­ter Ms Tasker’s over­dose on Septem­ber 22, her mum in­formed hos­pi­tal staff in Lon­don – but the in­quest found this new in­for­ma­tion “did not trig­ger any for­mal re­view of her care plan” and it wasn’t even of­fi­cially recorded un­til five days af­ter the event.

Dur­ing that cru­cial pe­riod be­tween her first over­dose and go­ing miss­ing, the only sub­stan­tial com­mu­ni­ca­tion be­tween Lon­don and North East health pro­fes­sion­als was a let­ter from a ju­nior doc­tor which was found dur­ing the in­quest to have “lacked force”.

Giv­ing ev­i­dence, one SLAM doc­tor said they were “ex­pect­ing” more in­for­ma­tion from NHS staff in the North East but noth­ing came.

The coro­ner re­peat­edly ques­tioned if their fail­ure to be more proac­tive in ob­tain­ing that in­for­ma­tion amounted to a fail­ure in their duty of care.

For­mally con­clud­ing the in­quest, the coro­ner said: “Rachel took her own life while suf­fer­ing from men­tal ill­ness and in part be­cause the risk of her do­ing was not recog­nised.”

She added that “ap­pro­pri­ate ac­tion had not been taken to min­imise the risk” of a sui­cide at­tempt fol­low­ing her first over­dose.

Speak­ing af­ter the in­quest and fight­ing back tears, Mr Tasker said: “The process has taken two years and it im­pacts on the whole fam­ily, her two sis­ters, her grand­par­ents.

“But the con­clu­sion we’ve heard to­day is what we wanted.”

Mr Tasker said they ob­tained a note writ­ten months be­fore his daugh­ter’s death, which made it clear she knew some­thing had gone wrong.

He said: “We know Rachel did not want other peo­ple to go through what she had from writ­ings on her computer we found af­ter her death.

“She wrote these notes at hos­pi­tal dur­ing a low point when she didn’t want to be on the ward any­more.

“But when I read it I knew she was talk­ing about more than that, she was talk­ing about all the years she had suf­fered when she just wanted to have a nor­mal life.

“As a par­ent, it’s heart­break­ing, but read­ing that as a doc­tor you think some­thing must change at a prac­ti­cal level.”

Both SLAM and the Northum­ber­land, Tyne and Wear NHS Foun­da­tion Trust were told by the coro­ner they must im­prove.

Mrs Dilks said: “I’m not con­vinced that the in­for­ma­tion that’s been pro­vided in re­spect of SLAM is suf­fi­cient to per­suade me that an­other in­ci­dent like this would not oc­cur.”

Both trusts have said they are im­ple­ment­ing changes to make sure vul­ner­a­ble peo­ple don’t get lost in the gap, which is cre­ated when two parts of the NHS fail to talk to each other.

Gary O’Hare, ex­ec­u­tive di­rec­tor of nurs­ing and chief op­er­at­ing of­fi­cer at Northum­ber­land, Tyne and Wear NHS Foun­da­tion Trust, said: “We ap­pre­ci­ate how chal­leng­ing this has been for Rachel’s fam­ily dur­ing this dif­fi­cult time.

“We have con­ducted a de­tailed re­view and have made changes to our prac­tice and pol­icy to im­prove the way we com­mu­ni­cate.

“We will now re­flect on the con­clu­sions drawn at the in­quest.”

A spokesper­son for South Lon­don and Maud­s­ley NHS Foun­da­tion Trust said: “We of­fer our sin­cere con­do­lences to the fam­ily and friends of Miss Rachel Tasker at this dif­fi­cult time.

“Fol­low­ing Rachel’s death a full in­ter­nal trust in­ves­ti­ga­tion was car­ried out and lessons have been learned to en­sure we make the changes which re­duce the pos­si­bil­ity of this ever hap­pen­ing again.

“We recog­nise that in Rachel’s case there were fail­ings in es­sen­tial com­mu­ni­ca­tion and in­for­ma­tion shar­ing.

“We have amended trust pol­icy to in­cor­po­rate guid­ance on man­ag­ing in­ci­dents and risks which oc­cur when a pa­tient is away from the ward and we will be re­view­ing these poli­cies fur­ther in light of the Coro­ner’s find­ings.”

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