Our Partner and Solicitor Shantala Carr appeared on BBC South East News on 21.02.2023 with her clients Amanda Jackson and Analee Chamberlain, widow and step-daughter of Pat Jackson who took his own life as a result of mental health failings by Kent and Medway NHS Social Care Partnership Trust (KMPT).
The family brought a medical negligence claim against KMPT which resulted in an apology, compensation and confirmation that the Trust had changed its practices.
Further details are provided below, including the BBC interview:
Patrick (‘Pat’) Jackson (born 10.08.1961) and Amanda Jackson met in 1998. He was a loving husband to Amanda, step-father to three children including Analee, father to Carlos, and step-grandfather to grandchildren.
Pat had worked in the electrical industry all of his life, having worked his way from a young apprentice to Managing Director throughout his career.
In 2013 and 2016 Pat had two acute episodes of depression, which both times were successfully treated with an inpatient admission to hospital and ECT (electroconvulsive therapy), enabling Pat to recover fully and return to full-time work.
In February 2018 Pat suffered a relapse of a severe major depressive disorder with suicidal ideation. He was referred to the Crisis Resolution and Home Treatment team (‘CRHT’), which is part of KMPT.
Between 14.02.2018 and 22.02.2018 Pat was being reviewed regularly for home visits where it was noted that Pat had previously had two effective courses of ECT and that he was having suicidal thoughts several times a day. On 18.02.2018 he told the CRHT that he felt so awful he couldn’t help thinking about ending his life and that he had thoughts of cutting his throat.
On 22.02.2018 Pat took a serious and life threatening overdose and cut his neck. He was admitted to the QEQM Hospital and required ventilation and sedation. On 25.02.2018 it was noted Pat’s ‘risks to self’ were high. On 26.02.2018 it was further noted that Pat continued to have suicidal thoughts and that although he would prefer home treatment as opposed to an admission, he would agree to an admission if Amanda couldn’t support him at home.
On 27.02.2018 the CRHT operational and Amanda discussed Pat’s previous mental health episodes and how ECT had been effective in the past. Amanda advised that if her husband’s mood did not lift she would explore his work insurance options for him to access ECT treatment through the Priory Hospital. The CRHT advised Amanda that ECT treatment was available under the NHS.
On 01.03.2018 Pat was discharged home from the QEQM Hospital. Subsequently he was being seen at home by various healthcare professionals from KMPT. A risk tool called ‘RAG rating’ was used, with ‘red’ indicating that the patient is considered high risk.
Between 02.03.2018 and 21.03.2018 there was contact between Amanda/Pat and KMPT at least 17 times, including home visits by psychiatrists and a brief informal admission to St Martin’s hospital between 13.03.2018 and 19.03.2018.
Throughout this period it was noted by KMPT that Pat was at high risk of suicide, that there seemed to be no improvement (in fact, there was a decline) and that ECT should be considered.
Amanda and Pat regularly pleaded with KMPT to start ECT or, in the alternative, to provide a letter of diagnosis so that they could get this arranged privately. It was noted by KMPT on 13.03.2018 that Pat was concerned that the ECT was going to take a long time to put into place. On 20.03.2018 they noted that Amanda had concerns about Pat not improving and that she asked again for a letter of diagnosis to arrange the ECT privately. On 21.03.2018 a psychiatrist reviewed Pat at home and noted that Pat had a history of recurrent depression which responded poorly to medication when he relapsed, that there had been a deterioration since the current relapse started, that he was recently discharged from St Martin’s Hospital as the ward was extremely chaotic, that Pat was unkempt, had poor eye contact, was very slow and hesitant in speech and low in mood and that Pat wanted to “hide” and “it all to stop” and was anxious to start ECT as soon as possible.
Sadly, on the morning of 22.03.2018 Analee found Pat in his garage, having taken his own life. He was found to have a six inch laceration to his throat and lacerations to his wrists and chest.
Amanda instructed Shantala Carr, Solicitor and Partner at Girlings Personal Injury Claims, to bring a medical negligence claim against KMPT. With the input from an independent consultant psychiatrist, it was alleged in June 2020 that KMPT was negligent, predominantly in relation to the following:
• failing to arrange and commence ECT in a timely manner;
• failing to provide a letter of diagnosis so that Amanda could arrange private ECT;
• failing to consider alternative medication/treatment when the medication provided did not lead to any improvement;
• failing to arrange an inpatient admission (voluntary or by section) to keep Pat safe.
It was further alleged that had the above failings not occurred, Pat would have been kept safe, treated appropriately with ECT and recovered.
KMPT formally responded in November 2020, admitting that ECT should have been provided and had this occurred, Pat’s suicide could have been avoided. They also provided a formal letter of apology. However, they denied that there would have been any significant improvement to his mental health.
Mrs Carr obtained further evidence from the independent consultant psychiatrist as well as Pat’s previous employers and related witnesses in order to put together a valuation on the basis that Pat would have been well enough to return to work.
Protracted negotiations took place with KMPT’s legal team and a settlement for Amanda was finally achieved at a mediation in November 2022. A meeting with the Trust in February 2023 allowed Amanda and Analee to voice their concerns with the Trust in person and explain the impact the Trust’s failings and Pat’s death has had on the family. Shortly prior to the meeting, the Trust provided details of how it had changed its practice in relation to ECT since Pat’s death.
Mrs Carr also brought a ‘secondary victim’ claim on behalf of Analee for her psychiatric suffering as a result of finding her step-father in the garage. Although the law surrounding ‘secondary victim’ claims is highly contentious, this claim was also successfully settled at the mediation.