The entirely avoidable death of our daughter, Sally, aged 22, in July 2014 due to clinical negligence and neglect leaves us with numerous anniversaries both recognised and shared by others as well as those only known and painful to us, her parents. Eleven years on, 22 June marks yet another anniversary, the beginning of our last holiday with Sally in the Lake District.
This year is particularly significant in that it is the first year the days and dates coincide with those in 2014. The memories of that last holiday and the approaching anniversary of Sally’s death just over a month later, for us this year assume an even sharper focus. Recollections are catalogued in our minds as visual and emotional snapshots of not only the lost life of our daughter, but the end of our life as her parents and our family of four. Unbeknown to us time was running out.
On Sunday 22 June we were looking forward to collecting Sally from the train station in Windermere only to then be diverted to Oxenholme when a late train meant that she missed her connection. We enjoyed being with Sally for the next few days although unfortunately on this occasion she was somewhat restricted with certain activities due to a physical injury. Although anxious and low in mood when she arrived, things improved over the next few days. A particularly cherished memory was when Sally and her mother enjoyed cocktails together prior to a meal at a local restaurant.
Sally’s last afternoon in the Lakes was spent canoeing on Derwentwater. The picture below shows her trying to retrieve her camera to give to me for safekeeping. In retrospect, although we had no knowledge of this at the time, these were to be the last pictures she ever took and had the camera been damaged or lost this would have been particularly devastating. We cherish these pictures as a memory of those last precious days together.
Exactly one month later, Tuesday 22 July marked the beginning of a rapidly downward spiral in Sally’s mental health culminating in her death three days later. As previously, when suffering periods of acute distress, communication with Sally was sparse during this time and we had no idea of her whereabouts or the catastrophic deterioration in her health.
The first indication we had that Sally was struggling far more than usual was late afternoon on Thursday 24 July when Sally spoke with her mother on the phone. Concerned, her mother invited her for tea, but she refused, and we heard nothing further that night. Subsequently, her mother spoke with Sally the following morning and learned that she was still extremely low in mood and had been trying to speak to either of her two Community Psychiatric Nurses (CPN’s) or her psychotherapist. Her mother offered to help, but Sally was reticent for us to be involved. However, on this occasion we were so concerned that the decision was reluctantly made that we needed to override Sally’s reticence as to our involvement and her mother rang the Community Mental Health Team and requested that one of her CPN’s get back to her urgently, which they did three hours later.
We knew nothing of Sally’s circumstances in those last few days. Gut instinct coupled with twenty-two years’ experience as Sally’s parents was enough for us to know we needed to raise the alarm. As previously with all mental health interactions we were refused any information because of the abuse of power wielded by the wholesale application of obligations relating to patient confidentiality, ignoring the fact that this obligation can be waived where there is risk to the life of a patient or potential harm to others. As revealed through the inquest process staff knew that Sally’s life was in imminent danger in these final days.
The inquest process revealed the shocking details that between Tuesday evening 22 July and Friday morning 25th July Sally requested an ambulance on six occasions. There were also five admissions to Accident and Emergency. Her psychotherapist and her two CPNs reported to be so concerned with her presentation that they agreed she needed to be admitted to hospital for her own safety. Sally knew this too and had begged the “gatekeepers” at the Crisis Service for an admission. Despite this, staff still refused to communicate with us. We could only relay our concerns and ask for an urgent response for Sally.
The final time Sally’s mother spoke to Sally was late afternoon on the Friday when she rang her to enquire whether anyone from the mental health team had contacted her, which she confirmed they had. Two hours later she was dead. Later that evening, shortly after we returned home from an evening out with friends, a police car turned into our drive and the world as we then knew it collapsed.
Whilst the worst imaginable had happened we had no idea that it would take a further eight years to establish the truth of those final days or the abject cruelty Sally experienced at her most vulnerable by staff from the Crisis Service.
Many of those who have sadly lost a child in similar circumstances know that grief is not a process to be navigated in bite-size chunks until one somehow conveniently “gets over it.” It is a life-long process, acutely painful and unpredictable with ever shifting focus and poignancy. This year, for us, will be particularly difficult as we replay every moment of the same day/date of those last four weeks of Sally’s life in June/July 2014.
Justice for Sally 