A Quest for the Truth: Perinatal Mental Health Care in UK Presented by Chris Bingley

1. A Quest for the Truth: Perinatal Mental Health Care in UK Presented by Chris Bingley Charity Registration Number: 1141638

2. Why I am here ……

3. The Utter Devastation of Loss ! • 1 Corinthians 13: ….faith, hope and love; and the greatest of these is love ! • Love ….. your best friend is gone, taken herself away from you • Hope ….. there is none, your dreams and plans destroyed • Faith ….. shattered by the knowledge that these are “avoidable deaths” • When nothing is left what do you live for? • Emily ….. Was too young to have a bond, babies just cry, eat, sleep and pooh! • What do you do when there is nothing left ……. what would you do ? • Grief is a process ……. you have to keep going to get through it? • Everything is dark, you can see no end, you have to find strength within you • You find help … and follow a path …. until you find light and yourself again • http://www.uk-sobs.org.uk/

4. My Inspiration My Inspiration: • Anthony Harrison, Angela Harrison Trust “You can make it through the grief ……” • Dr Margaret Oates, on reporting the findings of her Independent investigation into Joe’s death “It needs someone who has suffered to stand-up and shout out …… .. people listen to patients with a voice….it’s a powerful voice” • Katherine Murphy, The Patients Association Chief Executive “We need one voice …. professionals, charities and user organisations together” • Albert Pike, What we have done for ourselves alone dies with us; What we have done for others and the world remains and is immortal

5. Chris’ A Quest for the Truth • Why? • Personal Investigations • Results of Previous Investigations • History of a Failing Service • Unlawful and Negligent Deaths • NHS Internal Reviews • The Independent Investigation • Coroners Inquest • NHS Failure to follow Due Process • Failings By Mental Health Services • Mental Health Services Unlawful • Failings By Maternity Services • Maternity Services Unlawful • Failing and Unlawful NHS Trusts • Health and Safety Standards • Health and Safety Executive • Crown Prosecution Service • Who is responsible ? • The Francis Enquiry • The True Costs of Failure • The Consequences of Failure • Why I am here • Best Practice Treatment

6. Why ….? • Why Joe? • Joe was dedicated and caring nursing professional • Trained initially through Huddersfield Royal Infirmary to qualify as a Registered Nurse and then deciding to complete an Honours Degree at Huddersfield University • She spent 20 years working at Huddersfield Royal Infirmary where she was Sister on day surgery. • Her funeral attended by over 400 people included ex-patients and many of her colleagues from HRI • I felt all their eyes on me asking the same question that I kept asking myself… • Why ?

7. Personal Investigations After her funeral I started to investigate the surroundings and issues associated with Post Natal Depression (PND) and the severe form my wife was being treated for. I had serious doubts as to the care and treatment given my wife prior to her death. I performed a “Route Cause Analysis” and prepared my evidence consisting of: • Timeline of Key Events – a detailed and cross referenced analysis of medical records and personal and family recollections of events • Relevant Health & Safety Guidelines (NICE, NHS and Other Publications) - highlighting the perceived breaches in guidelines • Analysis of the Incidence of Postnatal Depression and Gaps in Service Provision • A data gathering exercise using the internet on Serious Untoward Incidents and the Independent Investigations performed within the Yorkshire & Humber Strategic Health Authority area. • FOI request of NHS Policies, Strategy, Contract and Performance documentation My research identified significant failings by the Strategic Health Authority and Mental Health Trusts and this data was used this to force an Independent Investigation into Joanne’s treatment and death.

8. Results of Previous Investigations 19 Previous Independent Investigations conducted by the Yorkshire and Humber Strategic Health Authority are available to the public. These show recurring failures in the treatment and care of patients and Carers consistent with Joanne Bingley.

9. History of A Failing Service 2003 to 2006 - Over this 4 year period analysis of Independent Investigations shows a recurring trend of similar issues with failings in treatment and recommendations recurring across 11 of the 17 incidents (65%), relevant to the death of Joe Bingley. 2007 to 2011 - SWYPFT were never commissioned to provide perinatal mental health services and therefore had neither the systems, training, experience or specialist qualified staff required. SWYPFT and the SHA have knowingly operated in breach of NHS Service Frameworks and NICE guidelines. 2008 - The Kirklees Joint Mental Health Commissioning Strategydetails ‘Gaps in Services’ with plans to implement changes by the end of 2009, relevant to Joe Bingley. 2009 - South & West Yorkshire Mental Health Trust postpone planned assessment of compliance to NHS Litigation Authority Risk Management Standards as they were not ready. Previously had been assessed as have only documenting process and not having implemented them. After double the normal mental health patient deaths an ‘Independent Review’ of Mental Health Services found no issues in service provision. The Strategic Health Authority rely on the SWYPFT management to take the lead despite previous investigations fault the quality of Internal Reviews. “The Board declares that all national core standards have been met over the period ……………(after application of thresholds)” 2009/10 - South & West Yorkshire Partnership Foundation Trust NICE Compliance End Of Year Report 20 NICE guidelines listed as “partially compliant“ out of a total of only 42 which are monitored …… i.e. ‘non-compliant’ to 48% of care standards 2009 – Directors of the South & West Yorkshire Partnership Foundation Trust and Yorkshire and Humber Strategic Health Authority sign-off declarations of compliance to care quality standards to achieve elite Foundation Trust status………avg. pay that year £250,000 in salary, benefits, pensions and bonus.

10. Unlawful and Negligent Deaths 168 potentially “avoidable deaths” deaths between 2003 and 2009 as a result of the failure by Mental Health Trusts in Yorkshire and The Humber to comply to legislation, Care Quality Standards and to follow safe systems of work. • Of the 21 recommendations and actions from JB Independent Investigation 13 had been flagged previously as issues with action plans supposed to eliminate the risks. • Between 2003 and 2006 Independent Investigations show 12 out of 19 homicides (i.e. 66%) raise issues in treatment similar to those by the death of Joanne Bingley. • In the 250 Mental Health Suicides between 2003 and 2009 this would result in potentially 168 unlawful deaths, if the same ‘unlawful’ or ‘gross negligent’ treatment occurred, due to a failure to follow legislation, care quality standards and safe systems of work. • Reports from “Multi-agency Workshops” and Risk Assessment on NICE Compliance detail that in 2007 booklets and information leaflets were available for patients and carers but by 2009 no written information was being provided, but state “information available on the internal NHS Trust intranet”. The failure to provide information is a failure to follow care standards and safe systems of work.…. it is also a failure to obtain ‘informed consent’ in breach of General Medical Council guidelines, the Carers Acts and NHS Choices guidelines and a failure to comply with the NHS Constitution (Health Act 2009).

11. NHS Internal Reviews Huddersfield Royal Infirmary - Maternity Care • The report fails to address key issues and aspects of the treatment, failed to interview key persons who treated the patient, in particular the 2 Breast Feeding Midwives who were encouraging a course of treatment when it was suspected she was showing signs and symptoms of Post Natal Depression. • The conclusions are fundamentally flawed, stating “we could not have known she was suffering from postnatal depression”, contrary to the written evidence in the medical records and statements of the midwives. Kirklees Community Healthcare – Health Visitor Maternity Services • The report was written on the 4th May as an ‘Internal Review’ without reference to any specific terms of reference or other guidance. • The report fails to cover key issues (Joe’s previous history and treatment for PND, the failure to perform 5 clinical risk assessments, etc.) making NO conclusions. South West Yorkshire Partnership Foundation Trust – Mental Health Services • Finds “internal processes” were followed and concludes whilst key things need to be improved nothing that was wrong contributed to the death. • The report fails to cover key issues and aspects of the treatment and care; concentrates on “internal policies and process” failing to cover independent investigations, legislation, etc; report emphasises “the reliance on the family”

12. The Independent Investigation Due to time constraints placed upon the investigation by the NHS it was agreed: • The investigation team was only able to review the clinical documentation, policy documents and staff written statements and records, without the benefit of investigators interviewing staff. • As the NHS were unable to identify investigators in Midwifery or Health Visiting, these areas were supposed to be reviewed and investigated at a later stage. The Results: 21 recommendations and actions for change including: • Specialist Perinatal Psychiatric Resource • New strategies and policies compliant to care quality standards • New and improved systems, processes and safe systems of working • Provision of written information to patients and carers • Mandatory contractual care standards and compliance measures The Independent Investigation concludes: “From the documentation there is evidence that Joanne Bingley should have been hospitalised on the 27th of April 2010 at least 3 days before her death. Further if she had been so treated would probably have made a full recovery”

13. Coroners Inquest The criminal standard of proof beyond reasonable doubt, represents the evidential hurdle or threshold that the coroner had to consider for suicide or unlawful killing. He resolved to return a narrative verdict, and his 21 statements of fact include: • A personal and family history of mental health problems as well as significant adverse life events befalling her in the last 5 years of her life. • By the 22nd April her condition was such that she was referred to the Mental Health Services who responded promptly. At and around this time she was expressing suicidal ideation, low mood, anxiety and a poor sleep pattern. • At a meeting it was determined she could be treated at home. I have found as fact that no discussion of other therapeutic options took place………informed consent has not been obtained. (one of many unlawful acts) • Independent medical care advice commissioned from Dr Oates and Mr Ketteringham. I have accepted their view that the possibility of admission should have been part of the initial treatment care plan and discussed with the patient and her husband as a treatment option if she either became worse or did not improve. • I find as fact that her health fluctuated and did not improve. • It is also their evidence that on the 27 April, if not before, there was clinical indication to be admitted to a Mother and Baby Unit. • It would follow from this opinion that if admission had taken place Joanne Bingley in all probability would not have died on the date or in the manner that she did.

14. The “Lessons not Learned” In December 2013, a little over 2 years after the Corners Inquest, the NHS Director of Nursing from the NHS trust that treat Joanne Bingley finally admitted in a statement issued into court that: • In all probability had specialist perinatal psychiatric treatment been offered, including the admittance to hospital in a specialist mother and baby unit, it would have been accepted. • Had specialist treatment been provided the patient, Joanne Bingley, would have been expected to make a full recovery. • Their (NHS Trusts) breach in duty of care was the probable cause of death Joanne (Joe) Bingley’s death was one of many avoidable deaths every year. The Independent Investigation into her death resulted in 21 recommendations for improvement and the NHS agreed an action plan with her husband to implement the “lessons learned” by September 2011. In April 2012 the Care Quality Commission reported on the NHS Trust that treated Joe: • Following complaints raised by the husband of a patient who had deceased (Joanne Bingley) their investigation found the NHS Trust had failed to implement “Lessons Learned” to acceptable care standards • Women in this specific user group (mums suffering severe PND) at risk • 2 other mums, being treated at home for severe PND, have since killed themselves

15. NHS Failure to Follow Due Process The Cover-Up Starts and Continues In the days after his wife’s death the Managers and Directors of the NHS attempted to cover-up their catalogue of errors, acts of unlawfulness and gross negligence attempting to silence any investigation and quest for the truth: • The Senior Managers and Directors planning the internal reviews stated; “guidelines are just guidelines and don’t have to be followed”; “these things happen”; “we did nothing wrong”; before even starting their investigations. • The conclusion of the Internal Reviews were not supported by evidence in the medical records; attempting to deflect blame onto the family and husband. • The NHS Executive refused to investigate the complaints of gross negligent manslaughter against the Yorkshire and Humber Strategic Health Authority stating it was for that organisation to consider the appropriate action. • The Department of Health first refused to acknowledge and then to investigate the complaints made, of unlawful death, gross negligent and corporate manslaughter. The NHS refused to follow the NHS complaints procedures in the investigation of suspected unlawful deaths and medical manslaughter, a breach of Health and Safety legislation and a breach of Crown Prosecution Service guidelines.

16. Failings by Mental Health Services Coroners Statements of Fact: • At a meeting it was determined Joe could be treated at home. I have found as fact that no discussion of other therapeutic options took place. • Informed consent has not been obtained in accordance with the General Medical Council's guidelines (in breach NHS Constitution, Health Act 2009). • I have accepted their view that the possibility of admission should have been part of the initial treatment care plan and discussed with the patient and her husband as a treatment option. • It would follow from this opinion that if admission had taken place Joanne Bingley in all probability would not have died on the date that she did or in the manner that she did. Independent Investigation: • 21 recommendations and actions for improvements

17. Mental Health Services Unlawful The Patients Association: Over 50% of Mental Health Teams providing Perinatal Mental Health treatments are acting unlawfully. • Reported in March 2011 their investigation into commissioning of Perinatal Mental Health Services across 150 PCTs: • 78% of PCTs do not know the incidence of PND in their region • 55% of PCTS are failing to follow NICE guidance, are not providing written information on PND to mums who may be suffering • 44% of PCTs are failing to implement NICE guidance, are not part of a clinical network for perinatal mental health • 63% of PCTs do not follow the NHS National Service Framework, have no Specialist Perinatal Psychiatrist to lead PND services There are legal obligations to inform ‘Patients’ and ‘Carers’ of their rights as well as legal obligations to inform patients of their treatment options. The information should be in writing and include whether treatment follows clinical standards, what risks are involved in accepting each treatment option and the information must be made available before treatment begins.

18. Failings by Maternity Services Coroners Statements of Fact: • A personal and family history of mental health problems as well as significant adverse life events befalling her in the last 5 years of her life. (i.e. Bells Palsy, CBT for Post Traumatic Stress, Postnatal Depression) • Protracted and difficult labour extending over 4 days. • 2 admissions to the Birth Unit in February and March 2010 Clinical Records: • 2008 Health Visitors advise treatment for depression following miscarriage • HV failure to perform any of the ante-natal or postnatal risk assessments • Midwifes suspicions of suffering postnatal depression • Failure to perform any risk assessments, make any referral, or inform patient of their suspicions or the risks prior to treating for breast feeding problems. • 22 missed opportunities to enquire into mental health prior to GP diagnosis

19. Maternity Services Unlawful Care Quality Commission: • The CQC reported in November 2010 their inspection of 100 NHS trusts Maternity Services found: • 20% NHS Trusts providing Maternity Services in Breach of The Law • An "embedded culture" of poor care and unprofessional behaviour • “Catastrophic failings” by NHS staff to provide basic care to patients. • Cynthia Bower, Chief Executive of the Care Quality Commission, has confirmed the CQC would conduct an investigation once they have reports from the Coroner. • But she does not have the power or authority to act upon the complaints of unlawful acts and gross negligence that have been raised and that ultimate responsibility for the failure of Directors of or NHS Trusts rests with the Minister of State for Health, Andrew Lansley.

20. Failing and Unlawful NHS Trusts Joanne (Joe) Bingley Case Study: Failure to recognise trends and learn from previous mistakes with similar issues and recommendations recurring across large numbers of deaths: • Of 17 ‘Independent Investigations’ over a 4 year period, 11 incidents (65%) involve similar treatment factors, recommendations and action plans as the Independent Investigation into Joe Bingley’s death • 168 unnecessary mental heath deaths, in Yorkshire and the Humber since 2003, due to potentially unlawful and negligent treatment. National Media Reports: Mental Health Trusts failure to follow NHS policy, NICE Care Quality Standards and professional and clinical standards of care: • Avon and Wiltshire Mental Health Partnership Foundation Trust • Lincolnshire Partnership NHS Foundation Trust • South West Yorkshire Partnership Foundation Trust Legislation and Due Process: The NHS has and is failing to follow due legal process, to acknowledge and conduct investigations in accordance with the NHS Constitution, Health and Safety Executive and Crown Prosecution Service guidelines.

21. Health and Safety Standards Health and Safety At Work Act 1974 According to the “Management Of Health And Safety At Work - NHS Obligations”, all NHS organisations are obligated to ensure risk assessments of any significant risks associated with clinical and non clinical activities are properly undertaken. This includes details of the assessment along with the resultant safe system of work: • The obligation to undertake risk assessments applies to all activities that present significant risk. • Managers at all levels, clinical or non clinical, are required to identify and assess risks to the health and safety of • employees, • patients, • contractors, visitors and • members of the general public, and develop and maintain safe systems of work to eliminate or reduce theses risks. • Systems of work ……. shall be formulated …… to ensure, so far as is reasonably practicable, the health and safety of all employees and other persons who may be affected.

22. Health and Safety Executive Health and Safety At Work Act • The reporting injuries, diseases and dangerous occurrences in health and social care: Guidance for employers, states that suicides are not considered ‘accidents’ and are not RIDDOR reportable. • However, deaths are reportable if: • It is suspected or known those treating the patient ….were aware the patient had a history ….failed to take this into account. • It is suspected or known treatment was…. not following a safe system of work • It is suspected or known there were serious management failures “All of which apply in the case of the death of Joanne (Joe) Bingley” BUT In a letter received from a director of the HSE “Health Care” is not one of their strategic objectives and they lack the resources to investigate and prosecute accept in exceptional circumstances

23. Crown Prosecution Service CPS Guidelines Cases of murder or suspected murder, including manslaughter whether Unlawful, Gross Negligent, Medical or Corporate, must be notified to CPS as soon as practicable. If any of the following characteristics are present the case should be dealt with by Complex Casework Units (CCU): • High profile / multi victim / multi defendant murders;  • Cases involving complicated Public Interest Immunity (PII) issues;  • Sensitive, serious or complex cases of major media interest e.g. allegations involving organisations with high public profile;  • Cases requiring consideration of gross negligence manslaughter and any case involving a fatality in which the investigation is being conducted in accordance with the "Deaths at Work" protocol • Medical manslaughter cases must be referred to Special Crime Division.  “All of which apply in the case of the death of Joanne (Joe) Bingley”

24. Who is Responsible ? • Individual Directors “Duty of Care”: • Failing to apply the “lessons learned “ is negligent according to the NHS Constitution (NHS Act 2009) • Health and Safety legislation states directors are responsible for maintaining robust and defensible risk management systems and failure may result in claims of unlawful death, gross negligent or medical manslaughter • Yorkshire and Humber Strategic Health Authority: • In an email to Chris Bingley Bill McCarthy, Chief Executive states: “Myself and the board of directors are responsible and make the final decisions….” • The Care Quality Commission: • In a letter to Chris Bingley, Cynthia Bower, Chief Executive states: “…. ultimate responsibility rests with the Secretary of State for Health” • When will somebody be held accountable for the failure to take action and act to protect mental health patients and the public from avoidable death ?

25. The Francis Enquiry For the NHS to ‘place the quality of patient care, especially patient safety, above all other aims’ we must have candour when mistakes happen and acknowledge all medical errors. • Only 24 per cent of the 140 possible contributory factors identified by the inquiry team had been identified in local investigations at the time of the incidents. • So 76 per cent of the learning from the incidents had been missed; a situation that there is an urgent need to improve. • As well as the new statutory duty of candour, greater use will be made of incident data, including a commitment for CQC to consider each hospital’s review of serious untoward incidents as part of its pre-inspection activity. • NHS England is to launch a program of new patient safety collaboratives, which will be expected to provide expertise on learning from mistakes and help to provide a ‘rigorous approach to transforming patient safety’. “Avoidable Deaths” cost the economy in excess of £300m every year…. But ….this excludes costs of NHS negligence claims, currently 1/5th of NHS Budget £18bn.

26. The True Costs of Failure The costs of just one “avoidable death” like Joe’s would cover the costs of providing all mums and dads with the information they require and the extra mother and baby unit beds needed. The estimated cost of the emergency response (£2m) and the economic costs of closing the Trans-Peninne train line for several hours (£20m), hardly feels relevant when compared to the widespread human costs. Proper care would have cost: 15p for the JBMF information card for mums & dads (900,000 *25p = £176,000 per year for all mums) 2p for the JBMF Severe Postnatal Depression checklist/leaflet (22,000 @ 5p = £1,000 for all sufferers) just £17,000 for the 56 days treatment Joe needed to live! £318 per day for treatment in a Mother and Baby Unit Bed The sad fact is each year there are up to 66 maternal suicides due to psychiatric causes of which 86% are “Avoidable Deaths” (diagnosis and treatment was possible). A single “Avoidable Death” such as Joanne Bingley cost the economy in excess of £22m and cost the NHS over £1m in legal fees defending for 4 years the negligence claims, irrespective of any payout after finally admitting to a breach in duty of care.

27. The Consequences of Failure • The death of Joanne (Joe) Bingley caused horrific trauma to her husband, to Joe’s family and to her friends. But it also had a significant impact on the lives of many others. • Many of those who witnessed Joe’s body being torn apart by the train, her internal organs being spread across the tracks, the blood pool that resulted and her upper torso being dragged along the tracks, until the train came to rest. were traumatised: • The 2 train drivers off work needing treatment • The members of public, off work needing treatment • The 7 year old child waiting on the platform to go to school • And many other people who had to deal with the incident • All this suffering as a result of the NHS staff failing to obtain “informed consent”, failing to provide access to specialist perinatal health services and failing to admit Joe to a specialist Mother and Baby Unit, even though places were available at the time of her death in Leeds, Manchester and Nottingham. • Following his wife’s death Chris was driven by his own grief and the despair to find out answers to his questions Why? • At the Coroner’s Inquest the true consequences and costs of the failure to prevent what was an “avoidable death” was brought home to me when told of the many others affected, including the 7 year old child that witnessed Joe’s death !

28. Why I am here …. • Why ? • Joe was a dedicated and caring nursing professional • In 20 years working at Huddersfield Royal Infirmary she enjoyed caring and treating those who were ill but also cherished her time mentoring and supporting others • There is a stepped change underway, back to the core values of “caring” and “putting the patient first” • It will take at least 10 years before significant improvements are seen in the provision of Specialist Perinatal Mental Health Services • The 3rd Sector, Family and Mental Health Servicesmust work together to create the Integrated Care Networks required to fill the gaps in mental health care, “provide support for those suffering in silence” and “eliminate the unnecessary suffering” and “prevent the avoidable deaths” that devastate the whole family.

29. Best Practice Treatment National Perinatal Mental Health Project Report – A Review of Current Provision (2011) Peurperal Pscyhosis 1 in 500 Mums Specialist Perinatal Mental Health Services Mother & Baby Units Specialist Perinatal Psychiatrists Non - Specialist (PNMH) Services Admittance to general psychiatric ward Crisis Home Resolution Teams – “gatekeepers” 1,412 per annum Severe Postnatal Depression 3% of Mums 21,187 per annum Mild to Moderate Postnatal Depression 10% to 15% of Mums NHS Integrated Care Networks(Examples) Nottingham, Southampton, Birmingham, Glasgow, etc. Non-specialist services- lead by PNMH Champions with support of GP’s, Midwives, Health Visitors, Care Workers, volunteers, etc. 3rd Sector Support (Examples) Family Action - support program & befrienders Net Mums- online CBT & chat rooms House of Light- call-line and drop in groups Joanne Bingley Memorial Foundation - raising awareness, training & education 84,750 per annum The Baby Blues 50% of Mums 353,124 per annum Numbers based on 706,248 live births in 2009 and the agreed rates of occurence

30. The Joanne (Joe) Bingley Memorial Foundation • Founders Statement • How we help • Parliamentary Commission into PNMH

31. JBMF – Founders Statement      Joanne, or Joe as she preferred to be called, was a nurse with over 20 years experience. She was dedicated, caring and diligent as are most health care professionals I have met. But Joanne was let down by the very NHS organisation that she gave everything to and just 10 short weeks after giving birth to her much longed for daughter Emily, whilst being treated for severe postnatal depression she took her own life.  “The charity exists to ensure future generations such as my daughter have access to the appropriate care and support, that services adhere to care quality standards and to inspire sustainable change in the perception and provision of maternal mental health services in the UK”

32. JBMF – How we help • How the foundation delivers it’s aims: • Website and information leaflets - we provide information on what you need to know so dads, grandparents and friends can help. • We publish stories in national media, Twitter, Facebook and our website to encourage open discussion and raise awareness • Knowledge of ‘Best practice’ – legislation, care quality protocols, befriender and peer support groups, self help, supervision, etc; presenting at seminars and workshops to inform commissioners, dept health, parliament, etc. on patient and service issues. • We provide training & education workshops for professional health care workers and volunteers • We have supported research including: • The Patients Association survey of Primary Care Trusts • Kings College User Group • Through links with MP’s and other organisations we inform NHS policy makers and parliament of service user issues and expectations • Supporting the Maternal Mental Health Alliance we work with other organisations to deliver improvements in PNMH services.

33. Parliamentary CommissionInto Perinatal Mental Health Proposed Scope and Terms of Reference: The inquiry will provide an independent review and detailed investigation to understand and highlight policy areas and issues Why? has there been a failure to implement Specialist Perinatal Mental Health Care Services across the UK following parliamentary promises after the death of Daksha Emson. Why? has there been a failure to implement “lessons learned” from Independent Investigations Why? Dads and Significant Others are not recognised as Carers by NICE even though “Home Care” is the primary treatment offered by Mental Health Crisis Teams What? are the implications and costs to society and the economy: • Mums - Unnecessary Suffering in Silence and Avoidable Deaths • Dads - Suffering from PND and Caring for Partners • The breakdown of Family Relationships • Early Years Child Development • General Public • Businesses Productivity and Employer Costs What? are the recommendations and actions to reduce “the costs to society and the economy ” of the “unnecessary suffering” and “avoidable deaths”

34. Finally Charity Registration Number: 1141638

35. Uncovering the truth “What I have uncovered about mental illness and the issues around it during my investigations and enquiries is both tragic and shocking. It is my hope and desire that by openly publicising the horrendous treatment given my wife and I that other people come forward and support my call for the implementation of the care standards and “lessons learned” required to prevent such catastrophic Never Events happening again.” Chris Bingley Founder

36. My Inspiration • My Inspiration: • Anthony Harrison, Angela Harrison Trust , on asking how he coped? • “You make it through the grief somehow ……but the loss never leaves you” • Dr Margaret Oates, author of the Independent investigation into Joe’s death, • on reporting the findings that Joe’s was yet another “avoidable death” • “It needs someone who has suffered to stand-up and shout out …… • .. people listen to patients with a voice….it’s a powerful voice” • Katherine Murphy, The Patients Association Chief Executive , on completing the survey showing the failure to commission services across over 50% of UK • “We need one voice …. professionals, charities and user organisations together” • Albert Pike, • What we have done for ourselves alone dies with us; • What we have done for others and the world remains and is immortal

37. Why I am here …… Why are you?