Episode 5: Dot's Story

Warning, this is a true crime podcast and is not suitable for all audiences. Please use discretion. This episode contains descriptions of suicide. Please take extra care whilst listening. This is episode five of a 10-part series. If you haven't listened to the prior episodes, please go back to the beginning so you can follow along. When our parents get older, we know that at some point, if we're lucky enough to have them around for so long, our roles will be reversed. The ones that cared for us as children will likely need some help and care from us as they become more vulnerable with age. But there are some cases where that care cannot be carried out by family members because they're living with a serious illness. Many of you may have seen your parents living with dementia, with cancer or heart conditions. The list sadly is endless. But in today's episode, we're going to hear what happened when a son entrusted Essex mental health services to look after his mother who was living with manic depression. But tragically, like the other 2,000 patients we're remembering in this podcast series, she didn't end up living with it. She ended up dying. I'm Naomi Channel and this is investigating Essex, dying to be saved. I'm petrified of something happening to one of my parents. But again, as I've mentioned previously when talking about my children, I've always worried about their physical health. Why have I not considered what would happen if my parents had a mental illness? And who would I turn to for help? Especially if they're elderly. Very rarely do we see pictures of elderly people in the media or on advertising boards for mental health charities. But of course, as we know, declining mental health does not discriminate. It could happen to any of us at any age. In 2022, the Charity Age UK said that over half a million people that were over the age of 65 were experiencing anxiety disorders. And just under half a million people over the age of 65 experienced major depressive disorders. The World Health Organization said that 14% of adults over the age of 60 live with a mental illness. I want to tell you Dot's story today with the help of her son Paul. Dot's full name is Doris Smith, which is affectionately known as Dot. Paul, can you tell me what was your mother like? Yes, my mum was born in Clark and well in London and then we lived in Hankley. I was born and brought up in Hankley with her. She was typist for Hankley Council. So from stuff from my family when my mum was younger, she was like quite the person at the party, but not really like that with me. My mum could be difficult. She got hard work. And I said this out of the funeral and I said yeah, my wedding as well. My mum was an amazing mum and she gave me an amazing childhood. So I'll always be grateful for that. Paul is an only child and his mother was a single woman. So when it came to looking after her in her older years, his wife Anna, his also a registered nurse, helped out too. Yeah, so I've been with Anna since 2007. She used to be an NHS district nurse and there she is an advanced nurse practitioner for a private medical company. So yeah, I've always, to be honest, with the episode that resulted in my mum's death and I just took control of the whole thing, to be honest, which is what I needed. Paul, when you were growing up or maybe even before you were born, had your mum had any mental health concerns or was she diagnosed with any mental health conditions at home? Not really, no, but she did in the mid-80s. I remember I was seeing a counsellor when I was a child. I sort of know why now, but she saw a counsellor, yeah, but it was no real mental health issues as I was growing up. 2012, it was quite sudden, not really any warning signs. It come on sudden, resulted in an admission to a psychiatric hospital in Clactin-10 Centre, which was actually really good. And I think she came out of there fixed, if you like, and then for a few years after that, she was fine. Dawn had been acting in a strange manner. She was often forgetting things and would say things that didn't make sense. And after treatment at a mental health hospital in Clactin-SX, she seemed to be doing much better. She was coherent and Paul said she looked happy. But the consultant psychiatrist told Paul that he believed his mother was suffering with manic depression. And whilst medication could help, he said that lifestyle changes would likely be more successful in getting his mother better. Paul said he appreciated this advice and care, but he did also remember the environment at the mental health hospital. Being quite difficult to bear witness to. It was a bit harrowing when I took her in there. And then at one point, I actually took her out because she was a voluntary patient. I visited with my cousin, didn't like what we saw. We took her out. Then we realised that we'd made a mistake and we took her back. It was a little bit like walking into the scene from one foot over the cook's nest with people seeing rocking and stuff like that. And I thought I don't like to look at this. But then we realised that she was quite bad and we couldn't trope at home. So we actually took her back. But she stayed voluntary there. She was never sectioned in 2012. It was all voluntary. And do you know how long she stayed for? Well, she was actually there for ages and then they actually said she could go home and she almost didn't want to. And then she started going home in the day. And then I think she started going home for a few nights and then gradually she just returned home. She was back to herself but never quite the same again. And then there was another episode in I think 2016. In 2016, Doc did have another episode. And this time she was put on a ward in Colchester Hospital. After a short stay, she was deemed well enough to leave. But in March 2020, whilst the world was being turned upside down due to the Covid pandemic, Doc had her third manic episode. I noticed that she was active on Facebook. Like two and three in the morning. And my mum was very like goes to bed at 11, gets up around six or seven. And we were noticing stuff like that. Then we were getting calls from She had a neighbour one side. And then my second cousin actually lived the other side. And we were getting calls about strange behaviour. And that's when we started visiting. Once again, tried to get mental health team involved. Not that interested. They were sort of saying that they were visiting saying she was normal. When we were saying that the behaviour she was doing was totally not normal. And he all sort of went from now. She was excessively spending, crazily spending. She was, she was going shopping at Tesco's at midnight doing the shop that would sort of feed her family of six. Also, my mum's house all the time I've been on the planet was sterile. It was so clean. And the house was going dirty. And I know that that wasn't my mum. One night we got a call from my neighbour saying, your mum's outside. This is at midnight. Your mum's outside. You know, dressing gown trying to go to the bank in a 10 centre. We actually called the police at night to report like a, because I'm two hours away from Clapton. And they wasn't interested. And I rang back and spoke to the duty sergeant. And he laughed at me on the phone and said when your mum walks down the end of the pier, we might go and have a look. So he said it wasn't a crime and it was nothing to do with them. And this time, Paul knew it was more serious than before. She went back to hospital in the march and spent a lot of time there without a formal diagnosis. He was all also told by doctors that in brain scans his mother had had back in 2016, they had shown signs of vascular dementia and evidence that she'd had a few mini-strokes. He had never heard this information before and it left him feeling frustrated. She finally gets sectioned after being in, I think it was culture, it's the hospital in a normal world she gets sectioned by a mental health practitioner and she finally ends up at Brumfield. At the end of summer in 2020, Dot was admitted to the Ruby ward in the Crystal Unit in Brumfield Hospital. They provide specialist mental health care to elderly patients, including those with dementia. It was open in 2009 by boxer Frank Bruno, who's publicly shared his own mental health struggles. This center seemed to be the perfect place for dots where tailored mental health care around people her own age, with staff trained in caring for the elderly, well that was all on offer, but Paul sensed that something wasn't right and he wasn't happy with the care that his mother was receiving. We visited Adele, initially thought that things were good, it was more towards the end that we were starting to have concerns. Some of the reviews that we did which were done by Zoom because of the pandemic were amateur. Every question I asked, they had no answer, they were looking at each other and that's when we were starting to get really concerned about the care. Shortly after Dot was admitted, she had a full in the unit. Her balance was getting worse and Paul flagged to staff that he felt that she was unsafe on her feet, but he said they didn't seem to pay too much attention to it. She had some bruising after her full but thankfully it wasn't too serious and she started to recover, but her mental health got worse. So she's in there for a while, the section gets extended because it runs out, it gets extended which we agree with. I'm visiting, she then sort of takes a hatred towards me and doesn't want to meet a visit so things become really difficult. The staff as well, I was doing really stupid things, I were ringing me at midnight telling me my mum wants McDonald's and I'm like, I'm 70 miles away, I can't physically get her McDonald's and they're not, but she really wants it. We actually got an Uber delivered there one night for McDonald's. I wasn't eating very well, I was noticed she was losing weight. A relative who hadn't seen Dot for years came to visit her in the unit and Paul remembers how shocked he was at seeing his mother. Paul said she was quote, "talking gibberish and not making any sense." A few weeks went past and Dot was finally diagnosed with vascular dementia. The plan was to transfer her to a care home for patients with dementia in Thoric Essex in a few weeks time. But during those last few weeks on the mental health unit, something awful happened. And Paul received a telephone call whilst he was at work. I'm at work one Sunday, I'll just know. My phone rang and I could hear it say I'm a bus driver so I can't answer my phone. Here it said I know a number. I heard a message got left and then they called me on the bus radio and said when you get to the other end, can you call the garage? And I thought it's something not right here. And I got to the end of the route. It was a text message from my wife. The phone call was that she'd had a really bad fall. It had caused damage to her brain and she'd been transferred to Brunefield Hospital and was on end-of-life care. I got picked up by someone at work. They drove me from Layton's down back to my house where a friend met us. And they took us to Brunefield, me and Anna. And my mum was just laying in the room, dying basically. And I watched that for four days. Paul was not expecting this. His mother had dementia, but as we know, it's a slow crawl and progressive disease. And there are usually some clear warning signs before someone is about to pass away. But this was sudden and shocking. But you might be thinking not out of the realm of possibility. Elderly people have falls and sometimes those falls can be fatal. But it was after that passed away, that the circumstances surrounding dot's death became known. I'm so sorry, Paul. To have this must be absolutely horrific to get that call. You said you sat with her for four days. Did you know that she was on end-of-life care? Did you ever think she was going to be okay and survive or did you know that this was goodbye? I remember one of the days whispering to my mum that it was almost like she didn't want to go. And I said to her, you can go. I'm old enough. I'm settled. I've got someone to look after me. Do you know what? It was a real strange feeling when my mum died. Because the family is very small and it's just me, I had to just get practical and people said to me, I don't know how you're doing it. I had to clear her ass out. I had to deal with her finances. I had to arrange a funeral and I had Anna to help me. I should just get on with it and people was like, I don't know how you're doing it. I don't know how you're doing it. Had no choice. And that just sort of took over. The circumstances surrounding dot's death go like this. Dot had been found lying on her floor by another mental health patient. She'd fallen and hit her head on the toilet. Dot should have been given a full risk assessment when she was admitted to the ward, but she didn't get one. If she had, it would have been protocol to ensure that she was put under observation and monitored regularly. But even more shockingly, was Paul found out that this had happened over 24 hours prior to him being informed that his mum was on end of life care. He was her next of kin and he had no idea when you were by her bedside for those last few days or maybe even before that. I know you said you had concerns about her care. How deep did they run and had Anna clocked on to it, for example, because I know that she is obviously medically trained. We realized quite early on in the summer of 2020 that things were not right. And Anna was very carefully recalled in dates times events who she spoke to. And I remember Anna saying, we will need this in a year's time when we sit in the inquest. So we sort of knew that things weren't right. It was still a shock. But yeah, we were pretty much switched on to something was going to happen. Now, the important thing is between her death and the inquest is when we become aware of Melanie Lehigh and the campaign that she was running. And then we get really involved with that. We go on demonstrations. And now we start to find out that my mum was just one of hundreds of all ages that were failed by E putt. And that's so we're like, when we get to the inquest, we're very involved with Melanie Lehigh and her campaign. Paul told me that when Melanie told him about the other families who have also had loved ones die whilst in the care of mental health services in Essex, he was shocked by the number of families as well as the vast variation of failings and the circumstances that led to each death. He found solace and support in these families, a Melanie in particular. And they supported him when his mother's inquest finally happened two years and three months after she died. Paul, I'm really shocked at the length of time that you had to wait for the inquest, because presumably your questions about the circumstances surrounding your mother's death were going unanswered. And during this interim between your mother passing away and the inquest, you have met Melanie, you've met lots of these other families that have all been failed in different ways. I just wondered, you know, so the inquest finally happens. And did you get the real answers? Did you get any type of peace from that or any type of closure. Can you tell me a little bit about the inquest? So the things that stand out was the way that E put and their staff when they were talking about their evidence. They basically, it was almost like we were at an inquest for a faulty car. They were talking about an object and the coroner had to remind them a few times that you are talking about someone's mum that's sitting in front of you. The things it stood at to me was some of the more senior staff. The consultant involved looked like it was just a a nuisance to have to be there. The head nurse to me looked like she wasn't that bothered. She didn't really care. There was some more junior staff that were visibly very upset. It comes out in the inquest they were doing a lot of work they shouldn't be doing. Was that to pick up the slack from asking them members? So things like within 24 hours of admission and assessment should be done on someone's mobility. That wasn't getting done. So a healthcare assistant was doing it. It should not be doing it. It should be a nurse. What come across in the inquest to me was how someone in a professional position that they've been in for a long time could be so incompetent and still be in that role. I used to sit there just amazed. I've always used this comparison that if an airline pilot had made the mistakes that they did and was that incompetent they would not be flying anymore. That's how I've always compared it. During the inquest there was repeatedly, I would sit there and the coroner would ask say the consultant or the head nurse or one of the other staffer question. It'd be like the false risk assessment was it done within 24 hours? No. Should it have been done? Yes. I'll write. But you didn't do it? No. And that's how the inquest seemed to just go on constantly. Did you do this? No. Should you have done it? Yes. Yeah. And that's what I mean. I can remember Anna's friend sitting there observing this and saying to me at lunchtime like, I just can't believe that a medical professional is getting away with this. And this was from a medical professional? And this is from a very experienced ex-A&E nurse who now works in the private sector as well. Anna picked up that they changed her medication but it wasn't recorded. And she questioned the consultant and he says, yes, I did change here. Anna said, but you didn't record it. He said, no, I forgot. Anyone looking at that would be able to determine that she had mobility issues. But she had no assistance in her ward despite having already fallen shortly after she'd got there. She was supposed to be on like she needed help to get off of her bed. I'll also, the room was fitted with what they call assisted technology, which electronically alerted the staff when she left her bed and moved around. That wasn't turned on. One thing was clear. Dot should have been under observation and should have been monitored continuously. And if a sufficient risk assessment had been done, then Dot's death could have potentially been prevented. The interval that she should have been checked, according to protocol, would be every 15 to 30 minutes. The inquest found that Dot's death may have been avoided if the risk assessment for her had been done within the first 24 hours after admission as per the guidelines. An eventual assessment was done 12 days after her admission and in the interim, Dot had fallen several times. If she'd been observed as she should have been, then the coroner said her fall could have been avoided, or the team member of staff could have broken her fall. Dot's fall was the direct cause of her death after causing a bleed on the brain. A physiotherapist said that if they had been consulted, they would have told staff that she needs assistance for her mobility at all times. Paul, I'm just so sorry that the inquest didn't really give you any answers. Having looked at some of the reports that are available online, you can see that there's no real answer that's been given. I mean, do you know why? Do you know why? Do you know why she wasn't given the proper assessment? Do you know why it took them 24 hours to inform you of her death despite you being her next of kin? Do you know why she wasn't checked regularly or why the assisted technology was turned off? Can you put your finger on on why? Actually, I don't want. I can't even place a finger on it because a lot of people is going to say it's short staffing. But it came out in the inquest. They were asked was they short staff because of COVID, and they actually said they were overstaffed because they chucked the other world and put everyone into one world. So the record to keep in software they were using does appear to be in inadequate and apparently they've changed that. They were copying and pasting most of the record keeping every day. And it did seem to be some staff involved. It was really good. The physio therapist involved. She come across is really good. She done a really good assessment and she gave all her recommendations, but then she left the hospital, went to her next job, and none of her recommendations was done. In inquests where one word can't sum up the cause of death, there is a narrative verdict, which is where a few sentences can describe how a person came to their death. And this was dots. The coroner wrote that the conclusion of the inquest was narrative with a medical cause of death via head injury, via a fall, and impacted by dementia and frailty. But the coroner did have some suggestions and recommendations of the back of concerns that had arisen during the coroner's investigation. The matters of concern were as follows. That the Essex partnership NHS Foundation Trust delayed the completion of a false risk assessment. Completed the false risk assessment with inaccurate information to access Doris Smith's risk, and updates were also inaccurate. They did not follow the advice of the physiotherapist, who said that they would have required Doris Smith to mobilize only with assistance of staff, and whether her levels of observation should have been changed. Neurological observations following a sustained head injury were not completed as required. Doris Smith had had previous falls on the ward, and her level of observations was not recognised in light of advice from the physiotherapist after each fall. The trust observation policy is used in different therapeutic settings and is confusing as to the levels of observation required. The focus is on risk for mental health, rather than physical health care issues that may arise. But of course, sometimes patients have both. The quality of record keeping was also a matter of concern. The Trust's medical records recording system is electronic, and evidence was heard that the window on the screen used for staff to type their records is very small and difficult to use. There were significant examples of cut and paste, including out-of-date information recorded in the medical records. There was a lack of effective communication as to the care and treatment required for Doris Smith between the trust staff and the levels of observations required to keep her safe on the ward. Paul, with everything that you had to undertake regarding all the logistics that you were talking about, that you had to do after your mum's death, and then you had to wait such a long time for the inquest and to really get any kind of answers. And even then, it doesn't seem like you've got many. How have you coped? Have you had a chance to grieve for your mother? I don't know if I've ever dealt with it. I'm sort of going through a bit of a weird time at the moment, and for a few reasons, but my wife reckons that I've never really grieved, and I don't know whether that point is sort of almost like past, but I never did it. Really really weird things happened like, um, it sounds a bit crazy but my mum's ashes are actually spread on the runway of London City Airport because it was, um, it was like a bit of a happy place for us. You mentioned it a few times. I thought this could be really difficult to do. London City Airport was amazing and actually arranged it when they closed one Saturday and they took us out on the runway and there was like a security bloke and the manager and Diana and two friends. I was comfort in the manager who was sobbing and I'm going, it's all right, it's all right and he's gone out, this is so emotional and I'm like, can't believe I'm comforting it in the stranger who's sobbing about my mum and I'm actually all right but once again it's like get on with it and do it. It's horrendous. The image of her laying in the bed on the end of life care is just, um, burnt into my eyes. Um, I also remember visiting her on the wall before the fall and she grabbed my arm and said you need to get me out of here because I'm going to die in here and that goes through my head every day. I'm so sorry Paul, especially from what you said about your mum you know how she gave you such a wonderful childhood and she was such a good mum and from the stories that you've told me before we started recording, it was, it was really clear and I just hope that through this horrible darkness that you can remember your mum in a positive way, what would you like to get out of this inquiry? And this sounds really horrible when Melanie hears this but I haven't even got that much faith in that public inquiry, if I'm a list. Um, look at the public inquiry into Gremfield, nothing's really happened, does it? No one's really been held to a can and I think we're going to have the same thing but it will, a statutory public inquiry does compel staff to give evidence and that's the important thing, they can be made to give evidence. We'll say, um, the weird thing was, it was an identical case to my mum in 2010 and when I say identical, it was a woman with dementia in the same world, the same age that had a fall that died from that fall and you read the inquest and its lessons will be learned, changes will be made just like all their serious investigations said but nothing does seem to change, um, they say they've changed their assisted technology, they've now got a better one, it's still happening, um, yeah. Did you ever receive an apology? Yeah, um, we got an apology, I did do a civil case against them as well before the inquests which they had made full one, um, all of the staff or nearly all of the staff looked at me at the inquest and apologized to me which I just didn't want to be honest. Sadly Paul's mother is not the only older person that has died in a mental health facility in Essex. 63-year-old Michael Nolan was a warehouse operative and a loved member of his local working men's club. He'd been married to his wife Janice for 38 years and he had a son called James but when his mother passed away, Michael's mental health started to decline. On the 22nd of June 2022, Michael attempted to take his own life. He was rushed to hospital where they managed to take care of his injuries and he was sectioned under the mental health act. Because he had made a serious attempt to end his own life, he was placed under constant one-to-one level three observations. This means that the patient needs to be kept in line of sight of one of the trained professionals working on the ward at all times. Just for your information, level four observations are used in exceptional circumstances where close care is needed and the patient is kept within arms reach of a trained professional at all times. After a matter of days, Michael's observation level was dropped to level two and it was decided that he should have four physical observations and engagement within one hour. The engagement here is important. By talking to the patient, the staff are able to have the chance to see any potential warning signs of potential decline in their mood or if they're entering an episode of psychosis. But on the 10th of July 2022, just three weeks after Michael entered the care of e-puts on the Kelviden ward at Baselden Hospital, he was found unresponsive and not breathing in his room. He had swallowed the lid of a roll-on deodorant bottle that was in his possession and he died that same day. Michael's family had handed them much loved husband and father over to these services to save his life. So how had he managed to take it in such a horrendous way whilst under the care of a team of designated professionals? The police looked at the notes that were taken by staff in the hours before his death. They said that he seemed happy and chirpy. An inquest was scheduled for March 2024, almost two years after he died and that inquest found serious failings by staff on the night he died. They found the observations were not carried out when they should have been and the engagements were not carried out as they should have been. There was evidence that there were failings when it came to their roles and responsibilities of different staff members because they weren't clear of what was expected of them. In 2023, the Care Quality Commission carried out an inspection into the observations of patients in Essex mental health units. Numerous patients had reported staff falling asleep when they were supposed to be watching the patients. This had been investigated previously and again the trust said they were going to make changes but if any changes were made they were clearly ineffective and the Essex partnership university trust went from being rated as good to requires improvements. You're going to hear from other families in this series. Families who have lost loved ones whilst in the care of the trust but the failings that contributed to the deaths of these lost souls are consistently different. There isn't just one reason why Essex mental health patients are dying, there are many. Next time we're going to hear from someone who was in the system but not as a patient as a member of staff and they're going to give their account of what they saw, what they heard and the truth behind the mental health units in Essex. Episode six is out and available to listen to now. I'm Naomi Channel and this is investigating Essex dying to be saved. [Music]