“The Joanne Bingley Case Study”
Joanne, or Joe as she preferred to be known, had trained as a nurse and worked for 20 years at Huddersfield Royal Infirmary caring for others where she was a sister in Day Surgery.
Joe had been with her partner Chris for10 years. Having married in 2005 they had tried unsuccessfully to have children, with Joe suffering several miscarriages. Health Visitor records detail how after one such episode Joe was referred for treatment suffering from postnatal depression (PND).
Joe and Chris had hoped that fertility treatment might offer a solution but they were not eligible and when they enquired into adopting they were told that their high BMIs (i.e. being over-weight) would be a barrier.
It was for Joe and Chris a miracle when in May 2009 Joe fell pregnant and was able to carry to full term.
When Emily Jane Bingley came into this world on 10 February 2010, her parents were delighted as she was a much sought after baby that they had come to think they would never get.
Joe was determined to do the right thing from the start and began breast feeding immediately to ensure that Emily had the best start in life she could give her…… but this soon lead to Joe’s despair and death!
Joe’s Pathway to Despair …!
The coroner at the inquest highlighted key dates in the pathway to Joe’s ultimate death:
2008 Previous Treatment for Postnatal Depression
- Previous termination, miscarriages and treatment for depression documented in Health Visitor records
- A prior history of receiving treatment for PTSD after her involvement in a car accident
- A maternal family history of PND, depression along with a young cousin committing suicide.
2009 Antenatal Check-ups
- NONE of the 5 mental health risk assessments described in the Kirklees Maternal Mental Health Care Pathway as the responsibility of Health Visitors were completed, with meeting checklists being completed for other matters but the questions on mental health left blank and incomplete.
- Joe’s physical health was the priority – her high BMI (weight), gynaecological issues, hyper thyroid, etc.
18 Feb 2010 Emily Jane Bingley Born after 5 days in labour
22 Feb 2010 Breast Feeding problems result in 1st Hospital stay with positive results
- Joe was admitted to Huddersfield Royal Infirmary so that the midwives could help her overcome the problems she was experiencing breast feeding.
10 Mar 2010 Breast Feeding problems result in 2nd Hospital stay, Joe reluctant to leave
- The medical records detail Joe’s inconsolable crying, anxiety, feelings of failure and state that Joe was suspected as “on the way to suffering postnatal depression“.
- Despite the suspicions of the Midwife Joe was suffering postnatal depression no clinical risk assessments were completed, no referral and no information given to patient or husband
- Treatment for her lack of hind milk and crying baby was to have Joe connected to a “double breast pump” between feeds with intent to increase milk production over 10 days.
- Treatment concentrated solely on the problems of Joe continuing to breast feed and left her bruised, in tears and inconsolable … not until her husband Chris asked about bottle feeding was advice given !
- Joanne was persuaded by her husband Chris to move to bottle feeding and for the first time in several days Joe was able to hold her baby in her arms as Emily fed and happily fell asleep.
- Having switched to bottle feeding baby Emily quickly settle d and started to recover her weight but Joe’s depression started over her fears that she was a bad mother and had starved her child.
- Very quickly this developed into a very severe form of postnatal depression that can pose a threat to the life of both mother and baby, as sufferers often feel suicidal.
14 Apr 2010 Easter Holiday weekend Joe suffers an emotional breakdown and collapses at home
- GP diagnosis and starts drug treatment for Postnatal Depression and lack of sleep
22 Apr 2010 Joe has suicidal feelings with plans to drive herself and baby into a wall
- GP listens to various options considered but ruled out by Joe to kill herself, as they would not guarantee her death
- GP refers to Mental Health Crisis Team, GP diagnosis of severe postnatal depression (suicidal)
22nd April 2010 Initial Assessment by Mental Health Crisis Team
- The Mental Health Crisis Team conducted an initial assessment resulting in a diagnosis of very severe postnatal depression.
- The Crisis Team advised that the appropriate form of care was “home treatment” with care being provided 24/7 by her husband and family.
- No other treatment options were considered or discussed.
- No written information of any kind was provided, nor any information on how to care for his wife.
23rd April 2010 Care Plan provided by Mental Health Crisis Team
- Care Plan provided to both the patient and the husband, marked as provided to ‘The Carer’.
- NO information provided about ‘Carer Rights’ and no ‘Carers Risks Assessment’ as described on NHS Choices Website, as required by The Carers Acts and care quality standards
- At no point is any referral made to specialist perinatal psychiatric services or to a consultant of any kind, in beach of NHS Service Frameworks and care quality standards.
27th April 2010 Mental Health Crisis Team record a decline in mental health
- The Independent Investigation states that the clinical evidence substantiates that Joe should have been hospitalised at least 3 days before she died:
Coroners Evidence regarding the visit by the Care Team that day:
When Joe requested “please take me with you” her request was ignored and brushed aside by the care worker treating her that day. In the same meeting Joe left the session unexpectedly (withdrawing from the treatment).
Despite Joe’s medical record detailing her suicidal plans, a decline in mental health and her obvious state of anxiety the care worker never explored Joe’s state of mind or the signs of the breakdown of her relationship with her husband and carers .
Whilst sat in her car ready to leave, the husband knocked on the care workers window to explain Joe had left the property without telling anyone.
Despite having recorded the husband’s anxiety and distress in her notes, knowing his wife was suicidal, she told him to contact the police if his wife did not return and then drove away!
29th April 2010 Final Contact by Mental health Crisis Team and by Health Visitors
- Mental Health Crisis Team Dr and Nurse visit AM – the husband Chris (The Carer) not attending but the patient’s mother is present:
- The Dr for the first and only time during the entire treatment records signs of improvement, and decides there is no need to discuss alternate treatment options.
- Health Visitors visit PM – husband (The Carer) not attending but paternal grandparents in attendance:
- Joanne went into crisis and for 2 hours the Health Visitors were unable to console Joe.
- Health Visitor recorded high levels of anxiety, despair, inability to cope, Joe feelings that mental health service wasting her time and her intent to withdraw from treatment
- After the visit Health Visitor contacts Crisis Team Manager who over rules HV concerns and ignores risks
- Health Visitor raises her concern of HV’s being unable to cope as she is told Crisis Team is planning to stop providing support, and she contacts her HV manager to log risks.
- Joe’s husband Chris came home from work as the Health Visitors were leaving. Left to face his wife yet again in crisis, spending several hours to provide the care and support she needed to settle and calm.
- No-one contacts the husband Chris (The Carer) to inquire of patient’s state or discuss risks prior to the Bank Holiday weekend.
Note: According to “The Confidential Enquiries into Suicide” the most significant risk factor or sign 24 hours prior to someone committing suicide is their “withdrawing from treatment” and cutting contact with care services.
30th April 2010 Joes Death
- On Friday 30 April 2010, when her daughter Emily was just 10 weeks old, Joe sneaked out from the family home early in the morning walked to a nearby train line and lay down in front of a train.
4th May 2010 Initial Response of the Mental Health Crisis Team after the Bank Holiday weekend
- On first day back at 9:05am the Crisis Team Manager contacts the Health Visitors, the medical records detail the purpose was to explain that at no time did Joanne show suicidal intent else they (The Crisis Team) would have taken action.
May 2010 NHS Support for the Carers and family following bereavement
Following Joe’s death nobody from the Mental Health Crisis Team that had been treating her contacted her husband Chris to check what help and support her needed.
- The clinical records detail how the Crisis Team Manger contacted the Health Visitors advising them as “he has the support of his family” DO NOT TO MAKE CONTACT FOR 6 TO 8 WEEKS
- Whilst expecting the grieving dad to cope with support from his family, the Crisis Team Manager went on to discuss members of her own team and members and Health Visitors staff being offered immediate counselling and support!
Thankfully the Health Visitors ignored that advice from the Crisis Team Manager and left a hand-written letter offering their condolences and telling Chris to contact them any time he needed their help or support... “Evidence of a Caring Profession”.
According to care standards Joe should have been referred to a specialist in perinatal psychiatry but those treating Joe were not specialists and they had no training or qualifications in this specialist area of acute care.
For information on Careing for someone Suffering Postnatal Depression Click Here
For information on the treatment and care that should have been provided Click Here
After Joe’s death her husband Chris pushed for an in-depth investigation into how her condition was managed by local health services.
There was an Independent Investigation undertaken by leading UK experts (including Professor Margaret Oates, OBE).
Their expert report released to Chris in Sept 2010 concludes:
- From the medical evidence available Joe should have been hospitalised at least 3 days prior to her death.
- If this had been done she would have received the treatment necessary which would have resulted in her making a full recovery.
The result was 21 recommendations for improvements required to reach care quality standards, including:
- Information on treatment options to be provided to patient and Carer
- Information to carers of their rights, their options and their support
- Training for staff in awareness and use of basic tools
- A specialist consultant in perinatal psychiatry to oversee specialist services
In October 2011, at the Coroners Inquest held into Joe’s death the Coroner issued a “Statement of Facts” that were casually relevant to her death. The statements of fact included:
- Joe had a 5 year history of previous adverse life events …. including being treated for postnatal depression following a miscarriage
- Joe had been admitted twice to hospital following the birth of her daughter and found the environment safe, and secure and had expressed her wishes not to leave
- The expert witness statement that hospitalisation should have been discussed both prior to the start of any treatment and if the patients (Joe’s) mental state declined
- That Joe’s mental state fluctuated during her treatment and in all probability did in fact decline
- The mental health crisis team failed to disclose or discuss any options other than home treatment both prior to or during her treatment, arguably failing to obtain “informed consent” in breach of GMC guidelines
- The Independent Investigation into Joe’s death, performed by eminent experts, found clinical evidence Joe should have been admitted to hospital at least 3 days before she died and if she had would have been expected to make a full recovery.
- ”that in all probability if Joanne had been offered a place in hospital she would have accepted and would still be alive today.”
The Coroner stated that “complex issues” exist as to the cause of death and on the evidence presented he was unable to determine to the criminal standards of proof, “beyond reasonable doubt”, whether those “complex issues” were the cause of her “unlawful death”.
Whilst the Coroner ruled on a verdict of “suicide” he refused to close the pursuit of action through other courts on causation of death stating that others may be able to take a different view of the ”complex issues”.
For a copy of the Coroners Statement and additional information Click Here
On the 18th December 2013, nearly 4 years after Joe’s death, the NHS entered a statement into court admitting to a breach in their duty of care that in all probability was the cause of death.
On behalf of the NHS the Director of Nursing admitted to a breach in their duty of care and that on the balance of probability Joanne’s death was caused by the NHS failure to follow the appropriate care standards.
Accepting as fact that if offered Joane would have agreed to hopsital treatment and that if she had been admitted for treatment to a specialist unit she would have been expected to make a full recovery from her severe postnatal depression.
After a 4 year legal battle that had devastating personal impacts financially, emotionally and mentally Chris was unable to find any comfort in the NHS finally admitting to the truth of their failure to provide the proper care that would have saved his wife. This was because:
- The NHS still fails to provide across much of the UK the “specialist perinatal psychiatric services” that are required
- The unnecessary suffering continues of over 35,0000 mums and their families every year, along with
- The devastating loss of life from mums who commit suicide when 86% are “avoidable deaths” according to the Confidential Enquiries into Maternal Death.
For more details regarding the issues surrounding Joes’ death click Joanne Bingley Case Study: A Reason to Act
Following his wife’s death Chris founded the charity The Joanne Bingley Memorial Foundation to raise awareness and provide education, training and support for those suffering from or caring for someone suffering Postnatal Depression.
Many NHS trusts have failed to implement the Care Standards in perinatal mental health, failed to “learn lessons” and implement recommendations from Independent Investigations and Confidential Enquiries.
Other mums, dads and families continue to suffer unnecessarily and other mums die “avoidable deaths” due to the failure of the NHS to provide specialist services compliant to care standards.
Care Quality Commission Report into South West Yorkshire Partnserhip Foundation Trust (Apr 2012)
After he had received conflicting reports from directors and staff of the Mental Health Trust responsible for his wife’s treatment, Chris requested the Care Quality Commission (CQC) investigate their failure to implement recommendations from the Independent Investigation into Joe’s death.
Following the request by Chris an investigation by the CQC resulted in a damning report (April 2012) of the mental health’s trust failure to implement “lessons learned” and the recommendations of the Independent Investigation:
Of the 21 recommendations for improvements required to reach care quality standards, several had either not been implemented or failed to meet the required standards including:
- NO specialist consultant in perinatal psychiatry to oversee specialist services
- NO training had been provided to staff in regards perinatal psychiatry and
- Planned training was not to the required standards, by a training provider by not qualified or experienced in the specialism of perinatal psychiatry (i.e. the unqualified training the unqualified)
Two years after the death of Joanne Bingley, the CQC report concluded that this specific user group (sufferers of severe postnatal depression) were still at risk from the service not meeting care standards.
Click her for CQC – Joe Bingley Review of Compliance Report Apr 2012
3 Deaths in 4 years by mums referred to the South and West Yorkshire Partnership Foundation Trust – Yet 90% are “Avoidable Deaths”
Since the report was issued by the CQC in April 2012 detailing “this specific user group at risk”, there has been two further deaths of mums suffering from severe postnatal depression/psychosis whilst receiving treatment at home by South West Yorkshire Partnership Foundation Trust.
According to the Confidential Enquiry into Maternal Deaths 86% of mums who die whilst suffering postnatal depression are identifiable, treatable and avoidable.
This means of the 3 deaths in 4 years at least 2 were “avoidable deaths” :
Apr 2010 – Joanne Bingley (Huddersfield) lay in path of a train at Huddersfield
Jan 2013 – Clair Turpin (Sheffield) jumped from John Lewis building in Sheffield
Dec 2013 – Roseanne Hinchliffe (Huddersfield) jumped from the Cliffs at Whitby
Across much of the country the NHS has either failed to commission the specialist perinatal services or the services fail to comply with care standards.
· There are between 40 and 50 “avoidable deaths” every year
· 50% of mums (35,000) are left “suffering in silence” too afraid to seek the help they need
When will NHS Directors be held to account for their willfull neglect to comply with care standards?
When will someone act to address these failures and the horrendous impact on families?
Other “Avoidable Deaths” ?
Roseanne Hinchliffe (Huddersfield, 2013)
Dad of new mum who fell from a cliff in Whitby only six days after giving birth to take legal action against Calderdale Royal Hospital
The dad of a distressed new mum who tragically fell to her death six days after giving birth is to take legal action against the hospital where she received care.
Neil Hinchliffe, 62, said that Calderdale Royal Hospital staff ‘failed’ his daughter Roseanne, who used to live in Shelley, by discharging her only hours after she was admitted to A&E despite a district nurse’s concern that she was suffering from psychosis.
Less than one day later on November 3 ‘Rosy’, as she was known to her family and friends, fell 80ft from cliffs close to Whitby Abbey after calling a taxi in the early hours from her home in Boothtown, Halifax.
The news comes after a coroner decided against a verdict of suicide and recorded an open verdict at the inquest into her death at Scarborough Coroner’s Court on Thursday (24 April).
Clair Turpin (Sheffield, 2013)
A mother of twins who had longed to have children committed suicide because she thought she was an inadequate parent.
Claire Turpin, 42, had struggled to conceive, eventually succeeding after lengthy fertility treatment.
But she went on to become acutely depressed even though she was caring well for newborns Jack and Eliza.
Three months after their birth, the married former hotel manager jumped from the top of a John Lewis multi-storey car park.
An inquest heard Mrs Turpin had been referred to a mental health team and became ‘paranoid’ about social services wanting to take her babies away.
Her mother Kath Sugden criticised the medical support she was given, telling the hearing: ‘All that happened was that Claire went to the doctor and came home with another batch of tablets.