Suicide Prevention – Missed Opportunities and Lessons Learned

“Is suicide preventable or inevitable?  For me, the answer to this depends on whether missed opportunities of the past are today’s lessons learned.  With this in mind I plan to share my lived experience with the social housing workforce and explore strategies to improve engagement between service users and housing staff.”  These words and this blog is by Mel Anderton, a member of IMHN’s Mental Health & Housing Experts By Experience group:

Mel’s son Jake

Bereaved by suicide is my lived experience.  I lost my son Jake to suicide in August 2015 after a 10 month battle with substance misuse and mental health issues.  Jake, unlike many males, was very vocal open and honest about what was happening to him. He was desperate for help.  He couldn’t have shouted any louder.  Jake’s situation was complex.  He was denied dual diagnosis and was passed from pillar to post, referred and re-referred.  It was a desperate situation.

At the Inquest into Jake’s death the Coroner concluded that Jake had been let down by disconnected services and missed opportunities.   A recurring theme was that of ‘engagement’.   Much was made by one organisation that Jake had missed an appointment.  The Coroner quickly pointed out just how many appointments Jake had attended and went on to say that considering how young and unwell Jake was he actually engaged very well.  The problem was that he kept having to continually engage with different people and different agencies.

A Regulation 28 to prevent future deaths was issued by the Coroner in which she outlined a number of recommendations.  I can remember reading the Regulation 28 and being completely floored by the comment ‘This has happened before and lessons have not been learned’.  This troubled me for quite some time.

I was totally consumed by what had happened to Jake for about two years. I kept busy following up the recommendations made by the Coroner.  I met with a number of professionals who had been involved in Jake’s care, including the Medical Director of NHS England, who talked me through the responses to the recommendations for change.

Jake’s Regulation 28 and the responses can be viewed on the Chief Coroners website. https://www.judiciary.uk/publications/jake-robinson/

Leading up to the 5th anniversary of Jake’s death (2020) I made it my mission to re-visit the recommendations from the Regulation 28.  My focus being, What would Jake’s experience be today?    What I found was hugely encouraging.  I can say with confidence that Jake would have a very different experience today and for me personally it was heart-warming and  left me with a sense of accomplishment for all those involved in bringing about these potentially lifesaving changes.  The agencies involved in Jake’s care are now firmly connected and all of the obstacles that stood in Jake’s way have been removed.

I wrote the following article about what I found.  https://thebookofman.com/mind/mental-health/suicide-preventable-or-inevitable/

What I hope to do now is, to look at how the lessons learned since Jake’s death, could benefit other services including housing in GM.

I recently spoke with Sarah Sturmer, Founder and CEO of Pure Insight, who work with care leavers and what she said to me really did resonate.

Some groups of service users can be described as ‘difficult to engage’ when in reality all they need are trusting, reliable relationships delivered on an outreach basis in places and at times suitable to them”.

“Signposting without practical support to access a service is often an ineffective approach to working with vulnerable young people.  Part of our Psychological Wellbeing outreach service is to practically support young people to reengage with the services and people around them such as GP’s Personal Advisors from the leaving care team, substance misuse services, JCP, Housing Officers.  Once they can do this independently we can focus on other aspects of their mental health”.

 

We need innovative ideas for strengthening the connections between services, a positive mindset towards mental health and an understanding that we all have mental health.

I look forward to being a part of this project (the Mental Health & Housing Experts By Experience group and the trauma-informed training for housing providers) and hopefully contributing to the development of a person centred approach to improve not only housing systems, but also the well-being of service users and the housing workforce in GM.

Mel Anderton

 

 

Published on September 29, 2021 at 1:50 pm

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