On the 6th anniversary of Sally’s preventable death as a result of clinical negligence, Sally’s Mum writes ……

Time passes, but the pain of losing Sally and the subsequent devastation of her loss to all those who loved her dearly, does not diminish. On 25 July 2014, metaphorically, the waters parted and our lives would from then on forever be divided into “before” and “after”. Before, we were a family of four and Sally’s adult life stretched before her. After, there were three of us, poleaxed, devastated and struggling on a daily basis to survive and support each other.

Today and every day I think of my only daughter who I never expected to outlive. I think of all that she was, still is to us, and what she might have become. We shared a common sense of humour and I remember her laughter and infectious smile. I reflect on her talent for music and miss the sound of her violin. I recall the ease of her academic achievements throughout her school life and her love of badminton, ice hockey, boxing and animals.

Living with the enormity of grief caused by the loss of a child is a burden like no other from which there is no relief. Knowing that the “professionals” charged with Sally’s care not only refused to protect her or show any care or compassion, but that they were abusive and cruel in the extreme, only adds to the weight of our torment.

In the early days following Sally’s death, we held the, somewhat misguided, hope that extensive investigation and a degree of tenacity on our part would eventually reveal the truth regarding the appalling circumstances surrounding her death. We had no inkling of the ferocious battle ahead of us in order to obtain even the most basic information. We had no knowledge of the rafts of professionals in NHS Trusts throughout the country whose principal purpose is to protect organisational reputation at all costs and ignore or frustrate the needs of families in their quest for the truth about the death of their loved ones. We knew nothing of the “inequality of arms” inherent in the coronial and other related systems. We had no idea that bereaved parents are actively discouraged from pursuing the truth regarding their child’s avoidable death or that their vulnerability is exploited by a justice system that denies them even their basic rights.  

As conscripts to an intensive learning programme in which we never wanted to participate, necessity has forced us to learn a great deal, though much of it has been both distressing and depressing. The knowledge that the obligation of the Duty of Candour on healthcare professionals is at best  lip-service, “Learning from Deaths” has been reduced to rhetoric and organisational reputation is regarded as paramount,  evokes feelings of despair, frustration, and fury and exacerbates the intense pain of  the whole tortuous process.

The formulaic responses of mental health trusts to these frequent catastrophic deaths is sickening in the extreme. “Serious Incident Reviews” generate “Lessons Learned” and “Action Plans” and Trust Boards, with access to minimal details, and even less interest, nod them through at Board Meetings. The frequency of untoward deaths and commonality of themes either eludes them or is of too little concern to shift the cultural inertia. This repetitive cycle, which is supposed to end with the “monitoring” and “review” of the agreed actions to ensure their implementation, in reality ends with “REPEAT”. While the mountains of paperwork generated by the system gathers dust on the shelf the avoidable deaths of those neglected and abused by mental health services continues unabated together with the subsequent iatrogenic harm heaped on their families.

Six years on, there is a tacit expectation that we are “moving on”. Sadly, only those that have walked a similar path will know that the notion of “moving on” is not our reality, serving only to support a convenient and reassuring notion that allows others to feel better, minimising the magnitude of our loss and suppressing the niggling doubt that what happened to us could indeed happen to anyone, even them.

Sally, we love you today as much as ever. We think of you constantly and miss your presence in our lives. We sincerely hope that those responsible for your suffering and cruel, unconscionable death and all those who have been involved in any way with denying, delaying and covering up the truth, will, at the final reckoning, have to wrestle with their consciences. We hope that at some stage they will reflect on what they did to you and your family and acknowledge the part they played and that ultimately, this could have been their daughter or son. We will continue to fight for the justice you deserve, Sally, in the hope that when others cry out for help their voices will be heard and they will be treated with care and compassion so your death may not be in vain.

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