I missed the call a few weeks ago while I was running an event at work, and found an answerphone message that went something along the lines of ‘it’s the coroner’s office, call us back’. When I called back, no one knew who I was or why I had been called. I had an anxious wait while they asked around the office, and by the time I got through to someone, I was just relieved to know that the cause of the phone call was to ask me to give evidence for an inquest for someone I already knew was dead. My friend had committed suicide almost a year before and I had given a statement at the time, and now I was being asked to be interviewed in the coroner’s court and give further evidence.
Prior to the inquest, it would have been nice to deal with someone with some sense of tact, or with adequate training, who could provide useful information. This didn’t happen. Instead, I dealt with someone who told me the wrong date for the inquest (‘oh that’s funny, I gave you the wrong date!’ Hilarious.) who was unable to email me details of the date, time and location of the inquest. To top it all off, he called to tell me that my friend’s father had informed him he would be travelling to the inquest alone, and did I not think he should be travelling with someone? As it was, I didn’t. I was pretty upset and stressed about the whole thing, and in regular contact with my friend’s dad. If he needed someone to go with him, that was his own decision. I wasn’t even travelling from the same part of the country but this apparently passed the coroner’s office by. I’m sure the man at the coroner’s office thought he was being caring and helpful, but in reality, the emotional blackmail was inappropriate and stressful. We had no idea where to get food or if anything would be provided, or how long it would take. Apparently asking for an events co-ordinator capable of using a calendar, providing useful information, and speaking to the bereaved with tact was out of the question.
Thankfully, on the day they took slightly better care of us. The coroner herself was very kind and approachable and tried to put everyone at their ease. The inquest is never used to apportion blame – the only purpose is to establish who the person was, how they died, when they died and where they died. We heard evidence from the pathologist who conducted the autopsy, the cognitive behavioural therapist, the hospital psychiatrist, the police officer who conducted the investigation, the housemate who found the body, and me, as a character witness.
Leading up to his death, my friend frequently told me that the health’care’ he was receiving was insufficient. That he was routinely dismissed, downgraded from urgent care, talked down to and passed from one doctor to another. That he found the therapy sessions to be distressing and draining and that he would go from one person to another, asked uncomfortable and personal questions about his mental distress and suicidal urges, only to be told he just needed to try harder to engage with the therapies and not to kill himself. He would go back home, try harder, give up, try to kill himself, give himself over to therapy again, get told to try harder, get sent home. Wash, rinse, repeat. There are only so many times that a vulnerable and sick person can go through this process before they begin to believe it isn’t worth trying any more, and stop asking for ‘help’.
I was expecting (hoping) to find some poor psychiatrist that knew he was in need of urgent care, maybe even inpatient care, who just didn’t have the resources to treat him. Other mental health professionals I know have this problem all the time – that someone is sick and clearly needs more care, but that there just aren’t the resources to give it. To some extent we saw this with his therapist, who identified that he was far too complex a case for the level of care she was trained and able to offer, and when he came to her saying that he had planned a method and date to kill himself, and just needed to get hold of the pills, she rang all the alarm bells at the hospital she could to try and get him more appropriate help.
What I did not expect was that this was an utterly pointless dead end. The hospital had three levels of care:
Routine: regular three-month checkups
Urgent: a worsening in condition that merited being seen in the next ten working days
Critical: the patient needs to be seen in the next four hours. The patient will do harm to themselves, or someone else without intervention.
Despite outlining suicide plans to a therapist and trying other methods in between (it presumably took a while to get hold of the pills he needed to die) my friend was never considered critical. We were given no answers as to what he would have had to do to be taken that seriously, to have someone believe that he meant himself serious and immediate harm. The psychiatrist simply stated that he had seemed articulate, intelligent and ‘with it’ and was therefore not a high risk patient. My friend was a well-spoken, intelligent, English graduate. Even on the day he died, none of his closest friends guessed at his intentions. Because those who are mentally ill and unstable are not all raving, gibbering maniacs incapable of stringing a sentence together. I know this – the psychiatrist on the other hand seemed flabbergasted.
All I heard all day was ‘we followed protocol’, or ‘it’s ‘XXXX’s responsibility really’ or ‘it didn’t seem like he was going to do it right away’, even when he told his therapist he expected to be dead within the month. My friend told his therapist he wouldn’t give her all the details of his plans as then someone would try to stop him. So when after a hospital appointment where the psychiatrist sent him home after another ‘try harder at your therapy’ consultation with nothing more constructive than a self help book, my friend discharged himself from care, and they simply wrote up the discharge letter the next day. No one saw the appalling lack of support as an issue. No one saw him telling the therapist that he ‘wouldn’t need anyone’s help anymore’ as a sign for concern. And then a few days later, he was dead.
But apparently, this is fine, because protocol was followed. Apparently this is fine, because he wasn’t a ‘critical’ case. Apparently, unless you are a raving lunatic, frothing at the mouth, you never will be. And nothing more will come of this injustice and that practitioner will just go back to following routine. I have never been more angry. I left the room, and called the man a bastard, a shite, a fuckwit, an uncaring cunt, a shit-for-brains and briefly felt better until I realised that I didn’t have the words to express my contempt for this man or the system he represented.
I don’t think that even with proper care my friend could necessarily be saved. He wanted to die. But I do think he deserved better – a better chance at getting well, more compassion, more dignity. And this inquest, distressing as it was, will do nothing to change the system that failed him so badly. And so I ask for three things from you today.
1.) Take mental health seriously. Attention-seeking isn’t a cause for contempt, it is a crude acknowledgement that help is needed. It is not a cause for shame or blame any more than cancer, diabetes, flu, or any other illness is.
2.) Mental healthcare isn’t always up to standard. If your friend tells you they aren’t getting help, take them seriously. Believe that some therapists are unhelpful and condescending or that care isn’t always available. Help them build a network of support so that they don’t have to rely on whatever the doctor offers.
3.) Talk about it. Change it. Don’t keep this issue hidden. Donate to Mind. Fundraise. Raise awareness. Don’t suffer in silence.