DON’T LET ANOTHER TRAGEDY HAPPEN
Josie jumped to death from bridge:
THE family of a girl who jumped to her death have urged Betsi Cadwaladr health board to learn lessons from the tragedy and improve their service.
Josie Rose James, of Clwt-y-Bont, Caernarfon, was found on August 6, 2015, despite the desperate attempts of a family friend to talk her out of jumping from the Menai Suspension Bridge
An inquest at Caernarfon heard Josie had been admitted to the Child and Adolescent Mental Health Services (CAMHS) in January 2014, referred by a nurse at Ysgol Friars, Bangor. Her mother, Joy, told the inquest that she’d started to self harm and could hear voices in her head, sometimes of a “murderous” nature.
With her condition worsening, she was prescribed anti-psychotic drugs in January 2015. In May that year, she was admitted to CAMHS’ specialist unit in Abergele, where she stayed for two months and was treated.
But Josie’s family said there was a lack of communication between the unit and them.
Despite Josie deciding to stop taking her medication, a decision was made to discharge her a week before her death, after she was declared “not suicidal nor at risk of self harm”.
Mrs James said no community support package had been put in place, and the family had “no idea what was happening.”
Psychiatric nurse Kate Roberts confirmed there had been a lack of consultation and communication with the family throughout the final few months of her life.
Josie’s friend Jonathan Retalik said she had called him on his mobile, saying she was on Menai Suspension Bridge and threatening to jump off.
North West Wales deputy coroner Nicola Jones said Josie had been saying goodbye to people and taking posters down from her wall before she was found.
Psychologist Phillippa Thomas said: “The way she coped with people was problematic for her.” Miss Thomas said she knew of an expert’s report which said Josie was having “murderous thoughts towards herself” a week before Josie was discharged and added that it would have been better if her family should also have had that information.
Consultant psychiatrist Dr Robin Glaze said it was “not unusual” that Josie had starting cutting herself before being discharged, but she was also said to be “happy and cheerful.” He confirmed, however, that Josie’s care plan had not being signed off before her discharge and there was no emergency number available for her to call.
CAHMS director Dr Peter ForeRees said: “Communication wasn’t clear. I think attempts were done but it wasn’t effective or clear. I think it’s completely clear that we need to improve.”
Giving a narrative conclusion, coroner Mrs Jones said that because of her state of mind, it wasn’t clear that Josie intended to jump off the bridge. Mrs Jones said: “Josie Rose James jumped from the Menai Bridge resulting in her death due to a ruptured aorta.”
A Betsi Cadwaladr statement said: “We offer our sincere condolences over Josie’s death. We acknowledge that there was not effective communication with her family.
“We are working hard to improve the ways we work with families, which includes ensuring they are supplied with treatment plans and additional information and advice to support the ongoing care of our service users. We have also set up a user group made up of service users, their families and our clinicians, which helps us to listen and learn about how to make meaningful improvements.”
In a statement, Josie’s mother Joy James said: “Josie was adventurous, fun loving and quirky, and made friends with everyone everywhere she went. She was outgoing, generous, confident, created art and wrote witty, thoughtful poetry. She achieved the Baden-Powell award, the highest youth award for girl guiding when she was 13. She became a qualified lifeguard. She planned to spend a year each on different careers, in between travelling the world.
“Her mind was tormented continuously, and we know that she may still have taken her life even if she had received the most comprehensive care possible. However, there are lessons to be learnt by the health board and it is our families greatest wish that everything is done in future to prevent this happening again to another young person.”