NHS Independent Review Panel

The provisional list of topics to be raised are related to the following areas:

1. The failure to recognise Post Traumatic Stress Disorder stemming from the tragic death of Belinda's sister Lucy.

2. Following Belinda's "wrongful" arrest, did the psychiatric hospital to which she was admitted have adequate facilities to treat her.

3. The inappropriateness of the medical decision that Belinda (who was a recognised suicide risk) should return to the police station associated with Lucy's fate, and her own "inappropriate" arrest. The associated apparent repeated failures in medical team working.

4. The events on the ward preceding her almost certainly accidental death in an attempt to get medical help and advice following a further police station error which wrongly led her to believe she had been charged. (The coroner's rider of neglect referred to this period.)

5. The lack of any psychiatric support to the family following her death.

6. The apparent inadequacy of the initial internal investigation, and the apparent attempt to withhold crucial evidence from the coroner.

7. Managerial shortcomings which were likely to result in substandard service for all, and not just Belinda.

In 1991 the NHS published a set of 12 priority guidelines to reduce the number of deaths among psychiatric patients. The paperwork for the inquiry suggested that the above topics demonstrate failures to meet 5 of these guidelines. There was a probable failure of a 6th guideline - which does not form part of the complaint. The remaining 6 guidelines are irrelevant to Belinda's case - so it would appear that Belinda's treatment can be faulted on every one of the relevant priority guidelines.

The Situation in January 2003

The Review is due to start on 3rd February and terms of reference have been drafted by the chairman - and commented on by me. For instance I have said that I expect that the word "normal" was tied to good professional practice, as purpose of the review is, in part, to ask whether what appears to have been "normal" on the ward was acceptable.

When the result of the review is released it will be posted here.

Afterthought 2006

At the hearing we were totally unaware who the witnesses were or what documents were considered. We then waited and waited and waited for the result - and about four or five months late a copy was posted to us without even the simple courtesy of a covering letter. While the report found that a doctor should have been informed of the incident on April 12th, two days before her death much of the document was quite obviously something that any competent professional would know was a whitewash. The review had been requested after the coroner had added a formal rider of neglect, and we had specifically asked that evidence revealed at the inquest be considered. In fact the review failed to even consider the existence of the inquest evidence, which included notes made by Belinda before her death, information provided by close friends, and matters relating to the "criminal" aspects of the case and Belinda's fear that she might end up being treated in the same way as Lucy.

We were distressed and horrified by the way we were treated, but at least relieved that by this time there had been a CHI report on patient safety and clinical governance which demonstrated what can only be described as widespread incompetence (which is what we had been trying to draw attention to). In addition many of the key staff had been moved to other jobs in different trusts (no-one is ever sacked for incompetence in NHS).

Having despaired for some months we decided that the best approach was to stop complaining about her death and take the matter of the unprofessional review to the Ombudsman. This we did in 2004 and this lead to an immediate response from the Trust. Apparently the new management took one look at the paperwork concerning the review, and the way we had been treated by the former management, and considered the situation undefendable. In the summer of 2005 this led to a formal complaint report, acceptable to us in the circumstances, about the way things had been handled after Belinda's death. Despite the Coroner's rider there has never been a competent independent review into the the death itself.