There are lessons to be learned but no one’s learning the lessons

When things go wrong in the psychiatric system and someone dies prematurely, often in tragic circumstances, there’s a mental health mantra which goes something like ‘lessons need to be learned’. But based on the fact failures and tragic deaths keep on occurring, it seems as though no one’s learning the lessons.

The mental health system in the UK is littered with failures that result in various internal investigations, independent investigation reports and Serious Case Reviews. Each of the investigations or reviews has a general purpose of finding out what went wrong so the same failings don’t occur in the future. On the basis that the same failings do occur and lives are being unnecessarily lost, something is desperately lacking and desperately wrong.

As an example, the mental health mantra of ‘lessons to be learned’ was used when mental health services in Sussex reviewed ten homicides linked to patients in its care. A Sussex Partnership NHS Trust patient Matthew Daly stabbed Donald Lock to death in July 2015, prompting the trust review, where it teamed up with NHS England to review 10 killings that occurred between 2011 and 2016.

Colm Donaghy, chief executive of the Trust said, “We believe going back five years will give us the information we need in terms of whether or not lessons can be learned.” Of course lessons can be learned, but it would have been optimum if they were learned after one killing, not ten. It’s not a case of whether or not they can be learned; they simply weren’t learned.

Another series of failings concerned Suffolk Mental Health Partnership Trust. In 2011, the trust released a report of its failings following nine killings in less than two years, all carried out by those who had at one time received treatment. The trust admitted it ‘failed to learn lessons.’ Who then is being held accountable?

The most telling example concerns Southern Health NHS Foundation Trust. It provides community health, specialist mental health and learning disability services for people across the south of England. It was the subject of a report commissioned by NHS England that highlighted a failure to investigate hundreds of deaths. The independent report, published in December 2015, said the deaths of mental health and learning-disability patients were not properly examined between April 2011 and March 2015. In March 2016, a Department of Health spokesperson said work was already under way “to ensure lessons are learnt both by the trust and across the system”.

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While it can’t be denied that some people do experience mental troubles that are sometimes very serious, the methods, ‘treatments’ used in the mental health system can often exacerbate conditions, or lead to iatrogenic conditions. The psychiatric drugs prescribed to people have been linked to violence, aggression, suicidal thoughts and suicidal behaviour. Coroners courts are littered with premature deaths of people who have been taking prescribed antidepressants. Thousands of cases are listed on the site After reading through the continual and repeated failures, it becomes apparent that lessons are not being learned.

All human rights organisations set forth codes by which they align their purposes and activities. The Citizens Commission on Human Rights (CCHR) is no exception. Its guiding principles and goals are articulated in the Mental Health Declaration of Human Rights. Part A relates to informed consent and is mentioned here as a potential starting point in bringing about positive change in the mental health system instead of coming up with new ways to justify failures.

A. The right to full informed consent, including:

1. The scientific/medical test confirming any alleged diagnoses of psychiatric disorder and the right to refute any psychiatric diagnoses of mental ‘illness’ that cannot be medically confirmed.

2. Full disclosure of all documented risks of any proposed drug or mental ‘treatment’.

3. The right to be informed of all available medical treatments which do not involve the administration of a psychiatric drug or treatment.

4. The right to refuse psychiatric drugs documented by international drug regulatory agencies to be harmful and potentially lethal.

5.  The right to refuse to undergo electroshock or psycho-surgery.

Click on Mental Health Declaration of Human Rights to read the full declaration.

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One Comment

  1. Strongly support this vital message/campaign from CCHR!Am pleased to be friends on facebook to Polly where I saw this campaign. Am a strong supporter of CCHR messages

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