Hearing Day 24 – Lydia Fraser-Ward and Alan Oxton
(10.58 am)
The Chair: Ms Troup.
Ms Troup: Good morning. We are ready to hear from our first witness, if she could be sworn.
Lydia Fraser-Ward
LYDIA FRASER-WARD (sworn).
Questioned by Ms Troup
Ms Troup: Could you state, first, your full name for the record, please?
Lydia Fraser-Ward: Lydia Lesley Summer Fraser-Ward.
Ms Troup: Thank you. Lydia, you are the sister of Pippa Whiteward, who died on 29 October 2016 when she was 36 years old. At the time of her death, her sons were five years old and four months old; is that right?
Lydia Fraser-Ward: Yes, yes.
Ms Troup: By way of background, the Inquiry sent to you under Rule 9 of the Inquiry Rules a request for Rule 9 evidence and, in response, you provided a witness statement which you should have a copy of in front of you?
Lydia Fraser-Ward: Yes.
Ms Troup: The witness statement is 59 pages long and, if you could look, please at page 59, there you provided a statement of truth and signed your witness statement?
Lydia Fraser-Ward: Yes.
Ms Troup: Are you happy that your witness statement is accurate?
Lydia Fraser-Ward: Yes.
Ms Troup: Thank you. That witness statement, as I think has been explained to you, now stands as your evidence to the Inquiry and, as a result, you understand I don’t intend to take you through that witness statement line by line, but please be assured that all of it has been carefully considered both by the Chair and by this Inquiry as a whole.
I would like to acknowledge that you also, Lydia, came before the Inquiry in September 2024 when you gave commemorative and impact evidence about Pippa’s death and also set out very detailed opening submissions to this Inquiry and to say, at this stage, that the Inquiry is very grateful for that evidence and for your detailed opening submissions at the time, as well as for your evidence today.
Lydia Fraser-Ward: Great.
Ms Troup: If we turn first – and I am hoping it will help if I refer you to the paragraph and page numbers as we are going along – I understand that there are a couple of matters that you want it raise in terms of opening remarks, first of all about Pippa’s illness and the fact that she was well for most of her life?
Lydia Fraser-Ward: Yes.
Ms Troup: Yes, so if you look at page 2, paragraph 8 of your witness statement –
Lydia Fraser-Ward: Yes.
Ms Troup: – you tell us there that, for most of her life, she was well and did not require treatment.
Lydia Fraser-Ward: That’s correct, yes.
Ms Troup: You go on, I’m so sorry, I didn’t mean to interrupt.
Lydia Fraser-Ward: No, she was. Pippa was a very – how you can you summarise a person’s whole life? Generally, Pippa was a happy, sort of comfortable, sociable person. She was actively involved in her community wherever she lived, in fact more than the average person. Wherever Pippa went, she got involved in groups, community activities, far more than me. I mean, I sort of looked up to her in that respect that it didn’t matter if she was staying somewhere only for two or three months, she would go there, she would get to know the place, she would make friends. She was really good at making friends with people, she was easy to talk to, she was a very good listener and it wasn’t as if she was sort of constantly in and out of hospital her whole life. That was not the case at all.
Ms Troup: Yes.
Lydia Fraser-Ward: Pippa was either working or being a full-time mum or in full-time education throughout her life and she was actively involved, like I said, in community groups. So when she died, she was a local councillor in South Woodham Ferrers, where she lived, she was the treasurer of the Parish Council for some time. I mean, her husband always used to complain, “It takes so long to get home because, whenever we go out, she gets stopped by everyone on the way home, they all want to have a conversation with her about something or other”.
Ms Troup: Yes.
Lydia Fraser-Ward: So she was very, very well loved within her community where she lived and a sort of very active person, I would say, in the world in general.
Ms Troup: Yes. You go on to say that – and this will become important – she really did have a very large and very close and loving network of support from family and friends?
Lydia Fraser-Ward: She did, yes. Yes. And, actually, as part of my preparation for this evidence, I was able to look through some of her old text messages, which was a bit of a unexpected sort of experience, and just the – I mean, she lost her phone only a few weeks before she died and, even with this new phone, it was just full of messages from friends saying, “How are you? How are you doing? Are you all right?” And she was in constant contact with people wanting to meet up with her and, obviously, she had a baby as well, so she was in a network of mums with young children as well.
Ms Troup: Yes.
Lydia Fraser-Ward: But she was you know very well loved by lots of people and I remember, at her funeral, there were so many people – I don’t need to exaggerate, it’s not hyperbole – there were so many people at her funeral, it was standing room only, so all the seats were full and then there were people just standing at the back. Everyone came out to celebrate her life –
Ms Troup: Yes.
Lydia Fraser-Ward: – because she was so well loved, yes.
Ms Troup: Thank you. The other thing that you tell us in the opening part of your witness statement, that I think is important to note now, is this you point out and ask this Inquiry to hold in its mind that post-natal depression is a very common condition and you have cited the figures: the NHS estimate that it affects 1 in 10 new mothers.
Lydia Fraser-Ward: Yes, I would say it may well be an underestimate.
Ms Troup: Yes.
Lydia Fraser-Ward: In my opinion, being a mum myself, I think all – from my experience, all the mums that I know are always concerned or worried about post-natal depression may be affecting them or even if you don’t have PND itself, you can often, as any mum will tell you, have ups and downs and you have highs and lows. It is an emotional roller coaster being a new mum, whether it is your first child or your 15th, and so, unfortunately for Pippa, it did affect her very severely.
Ms Troup: Yes.
Lydia Fraser-Ward: And I don’t know if she was predisposed to be at a higher risk genetically or just because of her personality or if she was just unlucky.
Ms Troup: Yes.
Lydia Fraser-Ward: But, unfortunately, yes, she did suffer from post-natal depression.
Ms Troup: Yes, and one of the other things you go on to say is that the more serious condition of post-partum psychosis, which is a diagnosis that Pippa also received, is much more rare and thought to affect around about 1 in 1,000 women?
Lydia Fraser-Ward: That’s correct, yes.
Ms Troup: But, nonetheless, what I think – and you must correct me if I am wrong – you are asking this Inquiry to hold in its mind is the fact that, although that condition is fairly rare, it is a condition what is triggered by a perfectly ordinary and very beautiful part of life, which is starting or adding to a family?
Lydia Fraser-Ward: Yes, that’s right, yes. It’s so desperately unfair. I mean, I think any mental health condition is desperately unfair, no one wants to be unwell, physically or mentally, none of us do, but it is something we all have to go through life, isn’t it, trying to keep ourselves in our best fitness, wellness, however you want it describe it. But, unfortunately, in Pippa’s case, she was affected by this rather rare condition, which can be recovered from. In fact, it in most almost all cases is recovered from –
Ms Troup: Yes.
Lydia Fraser-Ward: – which is so desperately tragic about her case, was that she should have made a full recovery –
Ms Troup: Yes.
Lydia Fraser-Ward: – if her medical treatment had been conducted swiftly and appropriately.
Ms Troup: Yes.
Lydia Fraser-Ward: And that’s why it is so terribly sad what happened to her because it didn’t have to happen.
Ms Troup: Yes. Thank you. Lydia, I am looking now at page 6 of your witness statement and, at the bottom of that page, starting at paragraph 18, you have set out some details about the earlier part of Pippa’s life and her history, the history of her mental health. One of the things I wanted to ask you about, you tell us there quite a bit about Pippa’s character and you tell us that, apart from being a high achiever, she was a person who inherently felt a pressure to achieve and to succeed; is that right?
Lydia Fraser-Ward: Yes, although it wasn’t obvious. That wasn’t obvious in her character at all.
Ms Troup: I see.
Lydia Fraser-Ward: If you met her, she seemed fairly laid back, quite relaxed. She was incredibly intelligent, far more intelligent than me. You know, she generally did well at school without too much stress or strain.
Ms Troup: Yes.
Lydia Fraser-Ward: There wasn’t a pressured environment at home to succeed, we were fortunate to have a good education, it’s not like – we didn’t have much money but we were fortunate to be privately educated because of certain schemes that were available at that time –
Ms Troup: Yes.
Lydia Fraser-Ward: – for children from, you know – I don’t want to say low-income families but from families that couldn’t afford to be privately educated, we both thankfully benefited from a placement scheme that allowed us to go to private school.
Ms Troup: Mmm.
Lydia Fraser-Ward: And so we were both very lucky that respect but, even if she hadn’t gone there, she always would have done well because she was very, very clever and she must have fixated on this need to be worthy, to be worthy of success, to be worthy of love, to be worthy of attention, and I don’t know where that stemmed from but that was something that was – has clearly come out after she died.
I didn’t really feel that through her life as her sister, didn’t ever feel like, “Oh, I am this high achiever, I must do this, I must do that”. I did feel that when she had children, perhaps she wished she could have done more before she had children. I did get the sense that, like, she may have wanted to have finished her degree, or she did end up finishing her teacher training but it was always later, everything sort of always got postponed –
Ms Troup: Yes.
Lydia Fraser-Ward: – in life and I think there was part of her that felt like was she going to have opportunity to do the things she wanted to do, which again, I think, all parents feel like that, don’t they?
Ms Troup: Yes.
Lydia Fraser-Ward: You think, “When am I going to get back to being me?”
But it wasn’t that she was like, “Oh, I must get A-stars in everything”. She wasn’t one of those people, she wasn’t this workaholic, anything like that at all and I think, actually, it was something that she kept that feeling, that need to be worthy, as I would say, more than achieve, sort of be worthy of love, of friendship, of success, was something that was deeply personal to her and actually quite private, and something that became far more apparent to me having seen her, you know, personal notes and diaries after she died. That was like, my goodness, I had no idea she was struggling so much with this.
Ms Troup: Yes.
Lydia Fraser-Ward: Because it’s not something that she ever shared with me directly, that feeling.
Ms Troup: I understand. I think that’s another matter that, that you note throughout your witness statement, which was that very often, even when she was in the depths of her worst struggles or particularly vulnerable, as you see it now, looking back –
Lydia Fraser-Ward: Yes.
Ms Troup: – because much of this you have learnt, as you have explained, either from her diaries or from seeing other documents after her death, as you see it, is this right, she was very adept at masking the struggles that she was going through?
Lydia Fraser-Ward: Yes, definitely. I mean, it’s – what’s the word I’m looking for? There’s a dichotomy, a struggle here because, in some ways, she was very open about her illness. She didn’t hide that she was having hospital treatment, she told friends that she was going into hospital, “I can’t meet you for lunch because I’m in hospital again”. So she never hid the fact that she was receiving treatment but I think what she did do was perhaps hide the extent to which she was struggling.
Ms Troup: Yes.
Lydia Fraser-Ward: She didn’t really want to show people how far she was struggling. She could ask for help but I think she found it difficult to perhaps admit – not admit but to express to friends and family the extent to which she was – she was struggling. She always put a brave face on things and she tried so hard to manage and cope herself, she kept trying to deal with it herself –
Ms Troup: Yes.
Lydia Fraser-Ward: – and deal with her treatment herself and perhaps she didn’t want to worry us, perhaps she didn’t want to be a burden. I think there was a lot of that at play as well.
Ms Troup: Yes.
Lydia Fraser-Ward: Certainly, she didn’t want to be a burden to her children, is something that sort of came up in her diaries and things and, you know, it must have been terribly hard for her, that struggle –
Ms Troup: Yes.
Lydia Fraser-Ward: – of accepting that she was unwell and trying to accept treatment to get better, for the sake of her family and her children and, at the same time, not trying to worry them and trying to be strong and be brave and to say “I will get better, I will get better”.
Ms Troup: Yes. You say that in the early part of her life there was an episode, I think, where, as you describe it, Pippa came under immense stress during her GCSEs and, at that stage, took an overdose of paracetamol?
Lydia Fraser-Ward: Yes, yes. It was – from memory, it was [I/S] it wasn’t a massive amount.
Ms Troup: Yes.
Lydia Fraser-Ward: And I guess that left this sort of uncertainty with us of was it a genuine attempt or was it a cry for help and, because she didn’t talk really much about what happened, certainly didn’t talk to me about it, it was hard to know, and she was so young, she was just a child, really.
Ms Troup: Yes.
Lydia Fraser-Ward: It was a very strange time for all of us that this just suddenly happened one day. I remember, “Pippa is not going to school today because she tried it take an overdose last night”. I was, like, “Oh, goodness, right”, and she just dropped out of school from that point on.
Ms Troup: Yes.
Lydia Fraser-Ward: And I had no idea what she was worrying about her exams. It never occurred to me and, even now, my mum has been saying to me, you know, she was so – it was so unexpected because actually Pippa was doing really well at school –
Ms Troup: Yes.
Lydia Fraser-Ward: – and she was a very adept pupil, she was very capable, so we had no doubt that she was probably going to do quite well. So we don’t really know where that came from –
Ms Troup: Yes.
Lydia Fraser-Ward: – because it was just so unexpected and, again, she must have been masking a lot of that worry and concern and not sharing it with us.
Ms Troup: Yes.
Lydia Fraser-Ward: And I don’t know why she was – I don’t know why she was afraid of failing because there was no indication that she was not going to do well. But, clearly, she had that concern, that anxiety.
Ms Troup: Yes. As far as you are aware, thereafter, Pippa had no particular struggles with her mental health until after birth of her first child; is that right?
Lydia Fraser-Ward: Well, that’s what I knew.
Ms Troup: Yes.
Lydia Fraser-Ward: I mean, sort of looking at different documents and things, sometimes there are references in the few, very few, medical notes that I have had access to, she’s clearly confided in a clinician and talked about – they’ve asked her about her history and she’s talked about, “Oh, well, I had struggles at this time and this time and this time”, but I mean it’s nothing that, that any of us were ever aware of, so if she was struggling in her 20s, none of us knew about it and it was not apparent.
Perhaps, in a scenario where she is opening up or reflecting and being introspective and really, sort of, ruminating on her past, maybe then when she is in an environment with a clinician and she is really thinking and reflecting, she might then go, “Well, actually my 20s were a bit like this”.
Ms Troup: Yes.
Lydia Fraser-Ward: So it could be that that’s why that’s in her notes, but it is certainly nothing that ever, ever presented itself.
Ms Troup: It didn’t become apparent?
Lydia Fraser-Ward: No, not at all and it was not like she was on any medication or having any treatment.
Ms Troup: No.
Lydia Fraser-Ward: Not to my knowledge, there was never any indication of that.
Ms Troup: Yes.
Lydia Fraser-Ward: No.
Ms Troup: Thank you. So if we move to the period after the birth of Pippa’s first child?
Lydia Fraser-Ward: Yes.
Ms Troup: What you tell us is that there was quite a fast downward spiral in terms of her mental health at that stage?
Lydia Fraser-Ward: Yes. I mean, again, it was quite unclear with her first son. She had the baby and then, after that, her behaviour just sort of changed. She didn’t appear unwell. She didn’t have any mania or anything like that. She just she seemed sort of tense all the time. You were afraid to sort of bring things up because you didn’t want to stress her out or worry her.
Ms Troup: Yes.
Lydia Fraser-Ward: I just thought maybe it’s just being a new mum, she was just tired and exhausted, but it felt like her personality changed, it felt like she was a slightly different version of herself. I didn’t see her as much as I would have liked to have seen her at the time because I was – I think I was still in my 20s or early 30s and I was working a lot, and I would go to visit when I could.
Ms Troup: This was 2011?
Lydia Fraser-Ward: Yes.
Ms Troup: Yes.
Lydia Fraser-Ward: I remember now, actually, she went into labour at my 30th birthday party and, in typical Pippa fashion, didn’t tell me. So we were all out and having a meal and she said, “I’m going to go home, I’m feeling tired”, and she’s obviously heavily pregnant and I only found out afterwards that she had actually been having contractions and been going into labour and just not said anything. So Pippa.
Ms Troup: Yes.
Lydia Fraser-Ward: So yes, my eldest nephew, I think, was born the day after my 30th birthday. So she did sort of – yes, she just sort of became a slightly different version of herself.
Ms Troup: Yes.
Lydia Fraser-Ward: And I remember thinking, “Oh, gosh, I really miss Pippa”, the way we used to hang out as sisters, rather selfishly, kind of just wanting to spend time with her and go out and go watch a movie together or something and knew that I couldn’t really do that any more because she was a new mum and she had to look after her baby. And I couldn’t fully empathise, having not had children myself at that time and being the younger sister. I mostly just wanted my bigger sister around had to hang out with.
Ms Troup: And have fun with?
Lydia Fraser-Ward: I knew she wouldn’t be as available.
Ms Troup: Yes.
Lydia Fraser-Ward: But I do recall, you know, from that time, although I wasn’t seeing her much myself, my mother was and she was worried about her, okay? There would be occasions where she became worried. So we were just talking about this morning. She went out and my mum became completely panicked about the fact that she had gone out for a walk with the baby on her own.
Ms Troup: Yes.
Lydia Fraser-Ward: She was so frantic. You know, she started going round town looking for her, and I was like, “Why” – you know, at the time I was thinking, “Why are you so worried, what’s the problem?” And if you were – you know, I think when she had gone out for this walk it hadn’t occurred to mum that it was a problem and then, suddenly, she sort of started to think maybe it is a problem and started to panic and worry about her and then started to look for her, and then she came home and it was fine.
But there was this sort of sense of “Is she going to be okay?” Like, she seems okay on the surface but you
can feel underneath there’s this tense nature just
bubbling under –
Ms Troup: Yes.
Lydia Fraser-Ward: – and sort of a little bit on egg shells with her.
Ms Troup: Yes.
Lydia Fraser-Ward: Of course, I only found out much later, after her death,
that she did in fact start to sort of – I don’t know if
she received treatment – she did, she started to
receive some cognitive behavioural therapy, but I had no
idea that that was happening.
Ms Troup: Yes.
Lydia Fraser-Ward: And she did receive this diagnosis of bipolar disorder.
Ms Troup: In 2011?
Lydia Fraser-Ward: Well, apparently yes, although I – there is so few
medical notes –
Ms Troup: Yes.
Lydia Fraser-Ward: – I can’t be sure of how reliable that is.
Ms Troup: So that information –
Lydia Fraser-Ward: Yes.
Ms Troup: Sorry, I didn’t mean to interrupt –
Lydia Fraser-Ward: Yes. No.
Ms Troup: I understand, Lydia, that the information about that
diagnosis having been given in 2011, in fact comes from
the NEPT care plan –
Lydia Fraser-Ward: Yes.
Ms Troup: – which was actually drawn up, as you understand it, as
best we can from the very few documents that you have,
that NEPT care plan was actually drawn up in June 2016,
following the birth of Pippa’s second son –
Lydia Fraser-Ward: Yes.
Ms Troup: – when she was at Broomfield maternity ward and
requested a mental health assessment.
Lydia Fraser-Ward: Yes, that is right. So it’s reflecting on historic
events and, therefore, it is sort of secondary
information. We don’t know how reliable a lot of this
information is because there are inaccuracies –
Ms Troup: Yes.
Lydia Fraser-Ward: – in many of the medical reports. So, therefore, the
exact year or date or location where she may or may not
have received treatment or may or may not have been
given a diagnosis –
Ms Troup: Yes.
Lydia Fraser-Ward: – I can’t vouch for the accuracy of it because it –
Ms Troup: Of course.
Lydia Fraser-Ward: – it seems to be sort of second-hand information.
Ms Troup: Or reflective information, as you say?
Lydia Fraser-Ward: Yes, yes, so there is a lot of uncertainty around that.
And, certainly, I had no knowledge of that diagnosis
until after she died.
Ms Troup: Yes.
Lydia Fraser-Ward: And I think there is a query, I don’t know if – I don’t believe, and again I am speaking for other people, but I don’t believe that either she, her husband or our mother ever believed that that was a true diagnosis. It could have been. [I/S] [I/S].
Ms Troup: Yes.
Lydia Fraser-Ward: And we are familiar with the kind of treatment and medication that is needed for a condition of that nature.
Well, Pippa never displayed anything remotely symptomatic of that condition –
Ms Troup: Yes.
Lydia Fraser-Ward: – in the whole of my life that I knew her. She never presented with any mania to me ever, or highs or lows, or any unexpected behaviour or any need for medication at any time.
Ms Troup: Yes.
Lydia Fraser-Ward: I am not saying that she didn’t have bipolar disorder I am just saying that, if she did, she managed it so well that none of us knew about it.
Ms Troup: Yes.
Lydia Fraser-Ward: And she herself may not have believed it to be the case. There’s sort of – the jury’s out on whether that was a diagnosis or not a diagnosis –
Ms Troup: Yes.
Lydia Fraser-Ward: – which again leads to more lack of clarity, I’m afraid, around the whole thing.
Ms Troup: Yes.
Lydia Fraser-Ward: There doesn’t seem to be any clear answer as to whether she really did have it or not. But we can suspect that she did. She was certainly – and I don’t know enough about – I know a bit about the disorder but not enough to know whether it is a spectrum and whether there are sort of early indicators –
Ms Troup: Or degrees?
Lydia Fraser-Ward: – or risks, exactly?
Ms Troup: Yes, yes.
Lydia Fraser-Ward: Yes.
Ms Troup: I understand. I understand what you say about being entirely unable at this stage to be able to confirm the accuracy of that kind of reflective summary that you have seen in the NEPT care plan from 2016. Apart from noting that there had apparently been a diagnosis of bipolar disorder in 2011, my understanding from your witness statement is that that care plan noted that in 2011, again reflectively, so from 2016, noted that in 2011 Pippa had experienced periods of mania and had, at that stage, made plans to end her life?
Lydia Fraser-Ward: I mean, it’s just news to me –
Ms Troup: Yes.
Lydia Fraser-Ward: – because it is not anything that any of us had ever heard about happening.
Ms Troup: I understand.
Lydia Fraser-Ward: So I guess the accuracy of this is going to be awkward because, if she’s being asked about this in 2016 when she is in a period of mania –
Ms Troup: Yes.
Lydia Fraser-Ward: – she may then be reflecting on things that aren’t true because she cannot judge for herself what is real and not real any more.
Ms Troup: Yes.
Lydia Fraser-Ward: And there was definitely – I do know that, certainly towards – just before she died, when she was in the throes of this illness, she did question what her memories were –
Ms Troup: Yes.
Lydia Fraser-Ward: – what were real and weren’t real any more. And so, I suppose, if the only medical notes we are going on are from those few short months when she was in a mania period, how can – anything that she was reflecting on from earlier in her life may or may not be an accurate reflection of what actually happened.
So –
Ms Troup: Of course.
Lydia Fraser-Ward: – unless I saw a medical document from 2011, which
I have never seen – I’ve never found, never heard of
anything from that period where she was receiving
treatment or feeling suicidal or anything, none of us
saw anything like that – then it is just her reflecting
on her own health during a period when she is unwell.
Ms Troup: Yes, because that period was immediately following the
birth of her second son when she was, and we will come
to this –
Lydia Fraser-Ward: Yes.
Ms Troup: – overtly unwell in a way that you were able to
notice –
Lydia Fraser-Ward: Yes, yes.
Ms Troup: – and you were able to see?
Lydia Fraser-Ward: Mm-hm.
Ms Troup: Coming to that, Lydia, I understand that Pippa’s second
child was born prematurely on –
Lydia Fraser-Ward: Yes.
Ms Troup: – on 10 June 2016?
Lydia Fraser-Ward: Mm-hm.
Ms Troup: As far as you are aware, despite the matters we have
been discussing that appear in that NEPT care plan from
after the birth of her second son, as far as you are
aware, had Pippa been provided, in the lead up to the
birth of her second child, with any sort of specialist psychiatric or midwifery support in relation to her mental health?
Lydia Fraser-Ward: As far as I am aware, she wasn’t. But she could have been and the notes have been lost. There is no reference to any specific planning –
Ms Troup: Yes.
Lydia Fraser-Ward: – in any of the notes that I’ve seen and she certainly didn’t tell me of any special planning. I do remember very clearly that when she told us the news that she was expecting a second child, I was – I suddenly had this feeling of deep fear and concern –
Ms Troup: Yes.
Lydia Fraser-Ward: – because, although nothing obvious happened after the birth of the first child, I do remember that she had become unwell and unpredictable, and I remember that episode where our mother had been concerned for her safety.
Ms Troup: Yes.
Lydia Fraser-Ward: And so she – you know, actually, by this time, sort of five years on, she was herself, she had been her old self. We had been hanging out together, she was finally sort of getting back into her life and I remember finding out that she was pregnant again, being happy for her, obviously delighted for her, but fearful.
Ms Troup: Yes.
Lydia Fraser-Ward: And I remember saying, the next day after that news had been told to us in person – it was Christmas time, we were all at my house and she told us – the next day speaking to our mother on the phone and saying, “You remember how ill she got lost time, so I’m just worried about that, just worried about her”.
Ms Troup: Yes.
Lydia Fraser-Ward: But that was all. So I was aware that, that she may become unwell but, obviously, she had had a child already and she had got through it and, to my knowledge, at that time, she hadn’t – I didn’t know she had had any cognitive behavioural therapy. So to my knowledge I thought she managed on her own and she got through it and she was fine –
Ms Troup: Yes.
Lydia Fraser-Ward: – so she can do it again. So it will be all right and we are here for her.
Ms Troup: Yes.
Lydia Fraser-Ward: So I was obviously very happy for her.
Ms Troup: Yes. I understand. When you went to visit Pippa – in fact, so the plan had been for her to have her – talking now about her second baby – to have her baby at St Peter’s Hospital in Maldon but, because of the unexpected premature birth, in fact, she was at Broomfield?
Lydia Fraser-Ward: Yes.
Ms Troup: I understand that just two days after her baby was born, you and your husband went to visit her there?
Lydia Fraser-Ward: Yes, it was about that time, yes, yes.
Ms Troup: Is it right to say you were immediately concerned about her state of mind?
Lydia Fraser-Ward: Not immediately. We stayed for a couple of hours.
Ms Troup: Yes.
Lydia Fraser-Ward: And you just have an instinct, don’t you, when just people that you are very close to, people that you love dearly, you recognise them and you recognise when they are not themselves.
Ms Troup: Yes.
Lydia Fraser-Ward: And I could just tell something wasn’t right. I just thought she’d just had a baby, she’d just given birth and she’s a bit out of sorts.
But, no, I could tell – all I said at the time after I – so I did the thing that I always do because I am a total clown, and I went there and I tried to make her laugh, and I was trying to make her laugh and I was telling jokes and being silly and mucking around and everything I was doing was clearly just irritating her, not – having the complete opposite effect of what I had hoped for.
And I was like, “Oh dear, okay, I am just making things worse, blah, blah, blah, I will just sit and chat”, and I gave her some gifts and then, yes, when we left, I said to my husband, as soon as we walked out of the hospital I said, “We shouldn’t have come, this was a mistake, I shouldn’t have come here”, and I remember saying that very clearly out loud to him and that was all.
Ms Troup: Yes.
Lydia Fraser-Ward: That was all I said at the time but I had a feeling that something wasn’t right. But it’s never this obvious, “I am unwell, I am clearly unwell”.
Ms Troup: No.
Lydia Fraser-Ward: It is so subtle, there are such subtle cues that you pick up on.
Ms Troup: From someone you know very, very well?
Lydia Fraser-Ward: Yes, exactly, yes.
Ms Troup: I think at places in your witness statement you describe her as presenting as upbeat and being able to smile but, to you, because of how close you were and how well you knew her and perhaps sibling instinct, and all of those other things, you could see that that thin veneer –
Lydia Fraser-Ward: Yes.
Ms Troup: – and that she just, as you’ve described it, I think, wasn’t herself, there was something not right beneath that veneer?
Lydia Fraser-Ward: Yes, she was coping, she was clearly tired, very tired but she was coping and she was muddling along.
Ms Troup: Yes.
Lydia Fraser-Ward: And, you know, it had been a premature birth, it was unexpected, it caught her a bit by surprise, she wasn’t, you know, expecting the baby so soon –
Ms Troup: Yes.
Lydia Fraser-Ward: – and the baby was having some light therapy, and things like that, so the stay in the hospital was longer than it would have usually have been. So it was a longer stay in hospital that, obviously, I imagine none of us prefer. We prefer to go home, don’t we? So …
Ms Troup: Is this right, when you visited her two days after her baby had been born, in fact, the baby was being kept in a separate part of the hospital than where Pippa was?
Lydia Fraser-Ward: Yes, Pippa had a separate room at that time and the baby was, if I remember rightly, it was a while ago, but it was in a sort of ward where there were other beds and other mothers and other children around, so her bed was not next to the baby.
Ms Troup: No.
Lydia Fraser-Ward: Her bed was somewhere else and I don’t know if she had requested a quiet separate room at that time or if she had been put there or they didn’t have enough space in that ward or what, I have no idea. But that was the case then, yes.
Ms Troup: One of the effects of that that you have now seen in the documents, I think in particular her diaries and the care plan that we have been discussing, is that where Pippa was placed in that hospital was busy and chaotic and noisy and she was really struggling to sleep?
Lydia Fraser-Ward: The room she was in was private –
Ms Troup: I see.
Lydia Fraser-Ward: – on that day. I don’t know if she had been in that room the whole time. But the room was under the helipad of the hospital, so the helicopter ambulances were landing on top, above her –
Ms Troup: Yes.
Lydia Fraser-Ward: – and she had been saying to our mother that that had been – there was very noise – a lot of noise from that that was keeping her awake. I mean, obviously, it is a hospital, you know, there is going to be noise but that, in particular, had been keeping her awake and she had been unable to sleep –
Ms Troup: Yes.
Lydia Fraser-Ward: – at all. As far as I am aware, she hadn’t slept since she had had the baby, for two or three days then, and she was becoming increasingly exhausted and tired.
Ms Troup: Yes. One of the things that you say – if you want to
look at it, you don’t need to but if you want to I am
now at page 11 and paragraph 33 of your witness
statement.
Lydia Fraser-Ward: Okay. Sure. Yes.
Ms Troup: One of the things that Pippa had reported is that she
hadn’t slept for seven days, due to, as you say, the
helipad, babies crying, alarms beeping, and the general
noise of a hospital ward?
Lydia Fraser-Ward: Yes.
Ms Troup: What you go on to say, given what we have noted about
what else is in that NEPT care plan and the apparent –
whether it is accurate or not – the record of
a diagnosis of bipolar disorder back in 2011, what you
tell us in paragraph 34 is that, thinking that through,
and knowing that sleep deprivation is a very well
documented trigger of –
Lydia Fraser-Ward: Yes.
Ms Troup: – of post-partum psychosis, you would have expected –
Lydia Fraser-Ward: Yes.
Ms Troup: – that information that Pippa was having sleepless
nights –
Lydia Fraser-Ward: Yes.
Ms Troup: – to have brought about some sort of action?
Lydia Fraser-Ward: Yes, I would have. I mean, why wouldn’t it, unless they
didn’t have her notes, which is highly possible, because she was in a different hospital from the one she expected to be in.
Ms Troup: Yes.
Lydia Fraser-Ward: Whether – did they have her notes or not, I don’t know, but if they had and they had seen that she was – either had a diagnosis of bipolar disorder or was at risk or had had a cognitive behavioural therapy after her first child, I mean surely – I mean, I recall from having my own children, you go through why you antenatal preparation, you get asked loads of questions, endless questions about your medical history, and they have all these notes about and your folder goes with you everywhere.
Ms Troup: Yes, yes.
Lydia Fraser-Ward: And, in my own case – so I had my first child after Pippa died but, because of what happened to her I said. “I could be at risk”. I’m fortunate, I am lucky, I have never had any problems in that area. I am lucky to not have had any concerns about mental health but, nonetheless, I wanted to be prudent and I said, “This happened to my sister, so I am going to tell you everything that happened to her and I want you to write it all over my notes so that if I start behaving differently, unexpectedly, I want you to raise this as a concern that I could be unwell”.
Ms Troup: Yes.
Lydia Fraser-Ward: Right? And thankfully that didn’t happen to me but, in
Pippa’s case that should have been all over her medical
notes that she was a high-risk patient.
Ms Troup: Yes.
Lydia Fraser-Ward: In my case, I was referred to a specialist team. Even
though I had no history of mental health illness, I was
referred to a specialist midwifery team as
a preventative measure.
Ms Troup: Because of the close genetic connection –
Lydia Fraser-Ward: Yes, yes.
Ms Troup: – and because it was a possibility?
Lydia Fraser-Ward: Yes, yes.
The Chair: Can I just ask you about that: that was in
Newham, I know?
Lydia Fraser-Ward: London Borough of Redbridge. I live in London Borough
of Redbridge but I was actually being treated at
a hospital in Waltham Forest, London Borough of Waltham
Forest, Whipps Cross.
The Chair: Okay.
Lydia Fraser-Ward: So that was part of NEFLT, it was part of the same
Trust, as far as I am aware. I am pretty sure Whipps
Cross is part of NEFLT as well, I think, I could be
wrong.
The Chair: What did that sort of preventative plan for you actually mean in practice?
Lydia Fraser-Ward: So it didn’t happen with my second son because I was well with my first child.
The Chair: Yes.
Lydia Fraser-Ward: I just went through the normal antenatal process for my second child. With my first child, I was referred to this special purple midwifery team, which meant that I had the same midwife for all of my appointments, I was given a contact phone number in case of emergencies if I felt I was unwell, if I had any burning questions about the pregnancy, if I was becoming concerned about the pregnancy, even after birth if I was concerned about the baby. So I had a number that I could call during working hours, it wasn’t a 24-hour number but it was a number that I could call and I had more frequent appointments, so many more appointments than you would normally have, I think sort of every three to four weeks I would go in, I would answer more questions, I would have more regular scans. There was a sort of continual kind of, “Let’s reassure you that the pregnancy is fine, you don’t need to worry, everything looks fine”, because obviously when you are having antenatal care, the scans are quite far apart. Anyone who’s had children, you sort of have one at 12 weeks, one at 20 weeks, and that’s it.
Ms Troup: Yes.
Lydia Fraser-Ward: Then you don’t know how it is progressing, and I can understand for many women that must be quite worrying, unless they have had children before, but for your first pregnancy, you might be, “Oh, I hope the baby is all right, I hope everything is okay”. And I actually had a further complication, I had a medical complication [I/S] with my first child –
Ms Troup: Yes.
Lydia Fraser-Ward: [I/S – details of physical health condition]
Ms Troup: Yes.
Lydia Fraser-Ward: So in some ways, it sort of went hand in hand with a physical condition, where they wanted to do extra scans just to make sure that I was okay. But Pippa should have had some sort of like regular at least continuing midwife, gone back to the same person –
Ms Troup: Yes.
Lydia Fraser-Ward: – so that they could have continued to assess how her pregnancy was developing and they would know her, they would know the details of the pregnancy. So every time you are going in, you are not having to once again explain triage and explain the whole medical history.
Ms Troup: Yes.
Lydia Fraser-Ward: So I think that consistency is very important for high-risk patients and it’s not above and beyond what’s possible because it is happening in other parts of the country.
Ms Troup: Yes.
Lydia Fraser-Ward: And I don’t see it as great expense. If anything, it would save the NHS money because it is preventative. The whole point is that it identifies if a problem is occurring before it occurs, rather than trying to deal with it and treat it after it’s happened, or treat a patient who suddenly develops significant like psychosis, which is a very serious condition. The whole point is to prevent that happening in the first place.
The Chair: Thank you.
Lydia Fraser-Ward: That’s okay.
Ms Troup: In fact, what happened, I think, to Pippa is that when her sleeplessness was discussed, and again this is something that you have been able to pick up from the records, the NEPT care plan that was put in place at that time simply states – the author states, “I do not feel that Pippa will need long-term support and she may
discharged in a week or two”.
Lydia Fraser-Ward: Yes.
Ms Troup: In fact, that is what happened and she was discharged on
17 June.
Lydia Fraser-Ward: Mm-hm.
Ms Troup: One of the things you tell us about here is that there
does not appear to have been – at least from the
records that you have and we understand that those are
limited, that that NEPT care plan, that in fact Pippa
had requested –
Lydia Fraser-Ward: Yes.
Ms Troup: – because of how she was feeling, she had requested
an assessment –
Lydia Fraser-Ward: Yes.
Ms Troup: – contains what you refer to as boilerplate wording.
It’s not a tailored care plan?
Lydia Fraser-Ward: That’s right.
Ms Troup: To you, it appears to have been almost oblivious to the
severity of the risk –
Lydia Fraser-Ward: Definitely.
Ms Troup: – to Pippa?
Lydia Fraser-Ward: No doubt about it. The only part of this care plan that
has any kind of detail is when it talks about her
personal history. So there is a long sort of drawn out
paragraph that outlines her mental health history and her medical history, which sort of says, “Oh she had had some problems with her first child”, et cetera, et cetera.
But then when it goes through the rest of the plan with the other questions about what the plan actually is to do and what’s the next steps and et cetera, et cetera, there is nothing there or it’s just a standard answer. It’s not signed by her, there doesn’t appear to be any contributions from her specifically. The only sort of personalised note is this note that, “She seems okay, I am sure she will be fine in a couple of weeks”, type comment –
Ms Troup: Yes.
Lydia Fraser-Ward: – which is a person that clearly doesn’t know anything about her or her history. Even though it’s in there that she’s had this history, there is no identification she is at high risk and, actually, looking back now, so with hindsight, she was in a period of mania when she was being assessed because, you can see from her diaries – so I think it was – this assessment was either the day she was discharged, or the day before she was discharged.
Ms Troup: Yes.
Lydia Fraser-Ward: That night she goes home and she keeps – she is very good at keeping diaries while she has a newborn and
she’s making notes every night of when the baby is going
to sleep, when the baby is waking up, feeding the baby,
all of these notes. That first night she was at home,
she has made more than, I think, seven pages of notes
going on, and on, and on in this diary.
Ms Troup: Yes.
Lydia Fraser-Ward: Doing this, doing that, sitting down, getting up, blah,
blah, blah. This is a person in a state of complete
mania. So she would have been manic during this
assessment.
Ms Troup: Yes.
Lydia Fraser-Ward: That’s not been – obviously not been picked up.
I don’t know how that could have been missed. But she
was already unwell at that time and it wasn’t noticed.
Ms Troup: Yes. In fact, I think that NEPT care plan records no
response –
Lydia Fraser-Ward: Yes.
Ms Troup: – in relation to all of the questions in it about
Pippa’s mental wellbeing?
Lydia Fraser-Ward: That’s right, yes.
Ms Troup: It also – because the plan, in fact, was for the baby
to stay at Broomfield and for Pippa to go home –
Lydia Fraser-Ward: Yes.
Ms Troup: – principally so that she could try and recover some
sleep?
Lydia Fraser-Ward: That’s right, yes.
Ms Troup: But as far as you can see from it, there appears to be no consideration, or certainly there is no record of any consideration, of how being separated from her newborn baby might affect her and the balance between –
Lydia Fraser-Ward: Exactly.
Ms Troup: – the need to sleep and separation –
Lydia Fraser-Ward: Yes.
Ms Troup: – from her newborn baby?
Lydia Fraser-Ward: Absolutely, and again, like, from looking at her diaries, there is this sense of guilt in the writing where she is saying, “Oh, I need to go home so I can sleep, so I can get better for the baby, but I feel guilty about leaving the baby, and I should be with the baby, and I should be caring for the baby”. So she is being torn in two different directions about feeling like she’s failing the child but also failing herself. She is so desperate to get better that she almost can’t.
Ms Troup: Yes.
Lydia Fraser-Ward: It’s exacerbating her situation and her condition.
Ms Troup: Yes, and I think those diaries that you are referring to, I think you say in your witness statement that it almost seems clear that she was unsupported with those fundamentally important aspects of that decision because she wrote herself – probably as you say, in a state of mania and desperately trying to do right thing by herself and everyone else, she wrote herself a pros and cons list about whether she should do what was being suggested –
Lydia Fraser-Ward: Yes, exactly.
Ms Troup: – “Will the baby feel I have abandoned him?” She also had a five year old at home – not a five year old but a younger child at home at the time?
Lydia Fraser-Ward: Yes.
The Chair: Do you think she could have masked what she was feeling?
Lydia Fraser-Ward: It’s possible. I mean, it’s – in Pippa’s case, it’s probable. It is probable. But I think, by that stage, it must have been apparent. I didn’t see her at that time. Obviously, I saw her several days before but I think, if she was in a state where she was writing the way she was writing, it must have been apparent by that point. I would be amazed if it wasn’t. I mean, certainly to a trained clinician, it should have been obvious, perhaps not to a person who didn’t know her or a person with no medication training but anyone that’s doing a psychological assessment surely should be able to tell if a person is in a manic state or not, and she must have been at that time. And the fact that most of the answers just say “No response”, makes no sense. Is it just that those questions weren’t asked, so that later when the care plan was typed up, they put “No response” because they just didn’t ask the questions because I find it highly unlikely that they would have asked her something and she just sat there as a selective mute – I can’t believe that either – or that would have been noted, surely “No response because selective mute”. It just doesn’t say because I am assuming that the questions weren’t asked.
And it’s so frustrating for me because all of the indications were there. Her history, her high risk and her asking for help, her going out and asking for the – it’s not like someone saw her and said, “You need to be assessed”.
The Chair: No.
Lydia Fraser-Ward: She had got to a point of desperation where she was saying, “Please, I want to be assessed”, because she herself could recognise that she was becoming unwell and she was asking for help, that’s what she was doing, she was asking for help as best she could.
The Chair: One of the only offers of support of any kind that appears to be referenced in that document is the offer of sleeping tablets?
Lydia Fraser-Ward: Mm-hm.
The Chair: She was concerned about that, as you understand it from her diaries and her own notes, because she was still breastfeeding –
Lydia Fraser-Ward: Yes.
The Chair: – the baby and didn’t – wasn’t clear on what the impact on him would have been?
Lydia Fraser-Ward: Well, the baby was only a few days old.
The Chair: Yes.
Lydia Fraser-Ward: And anyone who has had a baby knows those first sort of two or three weeks are so critical in terms of establishing breastfeeding. If you don’t keep it up, if you have long pauses, your milk supply can suddenly evaporate and then it all goes out the window, and she desperately wanted to breastfeed because she knew that was best for the baby and she didn’t want to jeopardise that. That’s why she was making so many notes about when she was feeding, how much the baby was taking, you know, we do that as new parents, you do that a lot. But those first few days are so critical, it is kind of all you think about.
And so the thought of taking sleeping medication that could be have adverse effects on the baby, she didn’t want to risk taking a medication that could harm the baby, especially as he was premature as well. So she put the baby first and decided that it wasn’t appropriate to take sleeping tablets because of that reason but she wasn’t offered – I mean, to be – I think by this point it was almost too late.
The Chair: Yes.
Lydia Fraser-Ward: She was so beyond the point of exhaustion, even when she did finally go home, she couldn’t sleep anyway. She was just awake all night, trying to sleep, trying to sleep, going downstairs, coming upstairs, watching TV, not watching TV, and writing about it in this diary constantly just “Got to get to sleep, got to get to sleep, got to try get an hour’s sleep”, anything just to try and recover. By this point she was obviously way beyond being able to just – all right just have a lie down and go off.
The Chair: Yes.
Lydia Fraser-Ward: You know, far, far beyond that point. She was clearly very unwell by this stage –
The Chair: Yes.
Lydia Fraser-Ward: – where, you know, she was going to need some sort of intervention.
The Chair: In fact, that becomes clear because, having been discharged from Broomfield, according to that plan for her to rest, within six days she was in crisis?
Lydia Fraser-Ward: Yes. Yes, she was.
The Chair: As far as you are aware, there was one home visit during those six days by members of a Community Mental Health
Team and you only know that because Pippa, again, wrote
about it?
Lydia Fraser-Ward: Yes, that’s, I – from – I mean, I would need to refer
to notes because I can’t quite remember from what I have
read where –
The Chair: Yes.
Lydia Fraser-Ward: – so many diaries and notes and different things. But
that’s something that she had noted down had happened.
The Chair: Yes.
Lydia Fraser-Ward: I don’t know if it was written anywhere in any of her
medical notes, as far as I am aware.
The Chair: No. If we come forwards in time to very late, on
22 June, I understand that Pippa’s husband contacted you
to cancel some plans that had been made?
Lydia Fraser-Ward: It was a Facebook notice to everyone that –
The Chair: Yes.
Lydia Fraser-Ward: – that plans to go out and have a birthday party were
being cancelled.
The Chair: Yes.
Lydia Fraser-Ward: And so we kind of all expected it anyway because she
just had a baby –
The Chair: Yes.
Lydia Fraser-Ward: – don’t really have time to be going out and having
birthday parties right now.
The Chair: No, and then I understand that later, much later, so around midnight on 22 June, Pippa’s husband contacted you –
Lydia Fraser-Ward: Yes.
The Chair: – and Pippa was in crisis?
Lydia Fraser-Ward: Yes. I think it was about midnight, and he doesn’t usually call me, so when he called me I was surprised, I was like “What’s happened?”
The Chair: Yes.
Lydia Fraser-Ward: And he told me that she was hearing voices and he was worried about her and that he felt he had no choice but to call an ambulance for her.
The Chair: Yes.
Lydia Fraser-Ward: And I was reassuring him, “You have done the right thing, you have done the right thing, she needs to be with people who with look after her, she’s clearly unwell, let’s just get her the treatment she needs”. And I remember staying up the rest of that night and I was online looking up mother and baby units – I didn’t know what a mother and baby unit was. I certainly didn’t know what post-partum psychosis was. So I was looking these things up, reading about them. I remember any friends I had that had any kind of medical background, I was messaging them in the middle of the night, saying, “You won’t pick this up until the morning but do you know anywhere that might have a bed for my sister?”
I mean, the fact that I was asking that means he must have told me that there wasn’t a bed for her somewhere. I think he was telling me that they were trying to find a bed for her.
The Chair: Yes.
Lydia Fraser-Ward: But they hadn’t found one yet, they were looking for one in London somewhere. I mean, my memory thinks of Hackney, I don’t know why I always seem to think they were trying find a bed for her in Hackney, or somewhere around there, but it didn’t work out.
The Chair: So Pippa was taken first on that night to the A&E department at Broomfield?
Lydia Fraser-Ward: As far as I am aware, from the medical notes I’ve seen, that’s what I am told.
The Chair: Yes.
Lydia Fraser-Ward: Yes.
The Chair: You at the time knew very little about what was happening there but it is clear that no bed could be found on a local mother and baby unit?
Lydia Fraser-Ward: As far as I know, that was right. That’s what I was told, yes.
The Chair: Efforts were then made, as far as you are aware, to find another bed somewhere else on a mother and baby unit?
Lydia Fraser-Ward: Yes, yes.
The Chair: You also understand, I think, Lydia, that although your knowledge of it is very limited, that it appears that Pippa had a very traumatic time during the short period that she was at Broomfield –
Lydia Fraser-Ward: Yes.
The Chair: – A&E?
Lydia Fraser-Ward: Yes. So she never told me what happened, I didn’t dare ask. I thought if she wanted to tell me she would tell me herself, she would volunteer it, so this was later, obviously, when she was out of hospital. On one of the short breaks she was out of hospital, after this happened, you know, we saw each other a couple of times on a couple of occasions and I wanted to ask her but I didn’t know how to ask her and I thought she will either tell me if she wants to or she won’t.
But I do know that from – her husband wrote – after she died, her husband wrote a letter to his MP, I think it was about a year later, it was either a part of sort of Mental Health Awareness Week or some sort of week like that, where he wrote to his MP and begged him for more beds on mother and baby units around the country –
The Chair: Yes.
Lydia Fraser-Ward: – and he published this letter on Facebook for everyone to see as well and, in it, he said, you know, “My wife was handcuffed to a bed” and, you know, treated like – left in basically a type of prison cell, a version – an NHS version of a prison cell, handcuffed to a bed while she was having a manic episode.
The Chair: Yes.
Lydia Fraser-Ward: And all I know from Pippa herself was, on one of the occasions I saw her, she asked me for my phone number and I said, “What on earth do you – you don’t have my number?” And she said, “I lost my phone”, and I said, “When did this happen?” And she goes, “You know, when I went into hospital, I lost my phone, and I don’t have anyone’s phone numbers”, and this was obviously weeks and weeks later –
The Chair: Yes.
Lydia Fraser-Ward: – after she’d been if Staffordshire and come back, she said she didn’t – and I said, “So you’ve not been able to contact me all of this time”. She was like, “No”, and wrote it down for her and I found in her diaries later, she has a back page of a diary where she’s handwritten phone numbers for her, you know, immediate family and close friends.
The Chair: Yes, so it was at that stage that you discovered that, we don’t know the circumstances, but her mobile phone went missing during that short period at Broomfield before she was transferred, and we’ll come on to the
confusion and uncertainty around where Pippa was
transferred to but she ended at Brockington Mother and
Baby Unit in Staffordshire –
Lydia Fraser-Ward: Mm-hm.
The Chair: – and during all of that time and whilst at
Staffordshire she didn’t have contact numbers for any of
her family or friends?
Lydia Fraser-Ward: As far as I know, she didn’t, but that was something
I found out later.
The Chair: Yes, one of the other things you tell us, Lydia, and we
can come back to it, is that you were unsurprisingly
shocked to hear that Pippa had been restrained in the
way that she was –
Lydia Fraser-Ward: Mm-hm.
The Chair: – that you consider that to be a last – that it ought
to be a last resort –
Lydia Fraser-Ward: Absolutely.
The Chair: – as a heavy-handed and oppressive measure for a young
woman who was in crisis?
Lydia Fraser-Ward: Absolutely. I mean, if you are having a panic attack,
the last thing you want is someone restraining you and
making you even more unable to control your environment
and your circumstances.
The Chair: Yes.
Lydia Fraser-Ward: So I am happy to share with the Inquiry that [I/S] [description of details relating to family] [I/S]
The Chair: Yes.
Lydia Fraser-Ward: [I/S] [I/S] [I/S] if someone is having a panic attack and melting down and worrying, the last thing you do is then restrain that person and, you know, hold them down, stop them from moving, stop them from going where they need to go. You might try and take them to a quiet place, you might try and calm them down, or give them space to calm down themselves. But, I mean, why were they handcuffing her was it because she was at risk of harming herself was she at risk of harming others was it because she was just being loud and screaming? What was it? What was the reason?
The Chair: Yes.
Lydia Fraser-Ward: There doesn’t seem to be any notes anywhere of why that choice was made and why on earth they felt like that was the best approach. It was simply for convenience, like this is a difficult patient, let’s just, you know, restrain them over here until they calm down, until the medication kicks in, which seems fairly archaic.
I mean, I’m not a – I’m not a medical person, I’m not a clinician but, I mean, it just seems fairly barbaric that someone who is crisis and terrified the thing you would do to them is then restrain them. Unless – obviously if they pose harm to themselves, if my sister was looking to hurt herself, I would understand it but there is no –
The Chair: Yes.
Lydia Fraser-Ward: I don’t know if that was the case because there is no reference to why that choice was made.
The Chair: The other thing that you note, and I think this comes from a recollection of your mother’s, is that a police officer was in attendance at some stage –
Lydia Fraser-Ward: Mm-hm.
The Chair: – when Pippa was admitted to Accident and Emergency at Broomfield and, in a state of obvious confusion and vulnerability and distress, she asked him, “Where is my baby?”, to which his response was, “What baby? There is no baby”.
Lydia Fraser-Ward: Yes, yes, that’s what she told me, yes.
The Chair: Which for a young woman in crisis, in the way that Pippa was at that stage, I think this links back in a way to what you have been talking about in terms of a continuity of care and the notes that you have described that are always sent everywhere –
Lydia Fraser-Ward: Yes.
The Chair: – with mothers for appointments.
Lydia Fraser-Ward: I mean, it’s unthinkable, unthinkable that something like that would happen. It might not seem like – it might not seem that important when you refer to someone just making a comment like that.
The Chair: I think it does. I think it does.
Lydia Fraser-Ward: But if you have had a baby, you will be having dreams and nightmares that you have lost your baby and waking up in a mad panic looking for them. That’s what everyone goes through when they have a baby.
So imagine that, compounded with the fact that you are in a manic state, you are handcuffed, you are in a strange place, and now someone is telling you, “There is no baby”, and you are doubting your sanity, your memories, what’s happened to you. I mean, that must have been utterly terrifying for her –
The Chair: Yes.
Lydia Fraser-Ward: – that that happened, I mean, “Has the baby – did I not have a baby? Did I not give birth? Did the baby get lost? Has it been given away? Have I hurt the baby?”
The Chair: Yes.
Lydia Fraser-Ward: I mean, it must have been utterly terrifying, you know, a new mother’s worst nightmare, to think that something might have happened to your baby or it’s been taken away from you.
The Chair: Indeed.
Lydia Fraser-Ward: So a trivial comment like that from someone who is untrained and completely unaware of how to support a patient in that crisis, you know, it shouldn’t have happened. It shouldn’t happen to anyone.
The Chair: No. Lydia, can I ask you to turn just, so that we can place ourselves within your witness statement, to page 16 and to paragraph 51. We don’t need to go through it on the page but this is where you start to explain what you know of what happened in terms of the efforts that were made and the transports and transfers for Pippa to be found an appropriate bed on a mother and baby unit.
Lydia Fraser-Ward: Yes.
The Chair: I think you understood from her husband, possibly at the time, that a bed had been found, possibly in London, but you are not sure?
Lydia Fraser-Ward: That’s what we thought at the time.
The Chair: Yes.
Lydia Fraser-Ward: That’s what I thought at the time. I will say “I”. I thought that a bed may have been made available for her in London but that she was turned away, she was rejected, and I don’t know for what reason but she was refused the only bed that was available.
The Chair: Yes.
Lydia Fraser-Ward: And when she was – what I was told – I say “told”, I believe it was in her husband’s letter to his MP – that she was transferred to Staffordshire because it was the only bed available in the whole country at that time on an MBU, on a mother and baby unit, so that’s why she was transferred hundreds of miles away because it was literally the only bed in the whole country.
The Chair: Yes.
Lydia Fraser-Ward: I don’t know about this reference to a patient being taken – I hope you don’t mind me skipping ahead to Margaret Oates?
The Chair: Not at all.
Lydia Fraser-Ward: As part of the preparation of this evidence, and having heard some of the information being provided to the Inquiry, there is this exhibit list – sorry, a spreadsheet, an out of areas bed list, that has been provided by EPUT.
The Chair: Yes.
Lydia Fraser-Ward: There are some rows. Obviously, the data is anonymised, so I cannot be 100 per cent certain that it relates to Pippa but it is so probably her, I can’t believe there could be another patient that went on this same experience at this exact some time, because the dates refer to this time in June 2016 when she was unwell, and it refers to a patient being sent to Staffordshire and later to Winchester where she went.
The Chair: Yes.
Lydia Fraser-Ward: But that, prior to this, this same patient was taken to Margaret Oates MBU, which I believe is in Nottingham, I think it is in Nottingham, but declined on arrival and sent back, and then it goes on to say “Patient admitted to Brockington following decline from Margaret Oates MBU, contact from Brockington MBU on 25 June”.
The Chair: Yes.
Lydia Fraser-Ward: But not clear if this was the date of admission.
So this piece of evidence that’s been provided by EPUT suggests that my sister may have been taken to Nottingham and declined and sent back to London.
The Chair: Yes.
Lydia Fraser-Ward: Now, if that’s the case, it is the first time myself, her husband or any of us have heard about that happening. So either that happened and we were never told, or it didn’t happen and this is completely inaccurate. Either way, neither is preferred – I mean, neither is good.
The Chair: No.
Lydia Fraser-Ward: How could there be so much – so little awareness of what happened to my sister –
The Chair: Yes.
Lydia Fraser-Ward: – and where she was taken? Why on earth would this reference even come up unless something happened in relation to Nottingham? Maybe they just enquired about Nottingham and she was declined and she was never sent there?
The Chair: Yes.
Lydia Fraser-Ward: I don’t know.
The Chair: Part of the problem for you, as I understand it, is exactly that, that you don’t know but, as you say in your witness statement, it either shows a very poor system of recordkeeping or a very poor process for communication with families and next of kin.
Lydia Fraser-Ward: Yes.
The Chair: In no circumstances does it show us anything good because there remains for you, even to this date, a complete lack of clarity about what happened to Pippa in those hours –
Lydia Fraser-Ward: Yes.
The Chair: – before she arrived at the mother and baby unit in Staffordshire?
Lydia Fraser-Ward: That’s right. I don’t really know what happened to her, no.
The Chair: The third possibility is it is just a totally chaotic and inappropriate transfer process.
Lydia Fraser-Ward: I mean, if there are so few beds, if there are really that few beds in this country for mothers with young babies who are having a mental health crisis that they have to ferry them around in ambulances, hundreds and hundreds of miles, just to give them a bed, then we are in really dire circumstances, aren’t we, because these are highly vulnerable – they are vulnerable patients anyway because they are having a mental health crisis. They also have a very young vulnerable person that they are responsible for caring for, keeping safe and keeping alive –
The Chair: Yes.
Lydia Fraser-Ward: – and in this critical time when they are trying to bond with this new person in their life, potentially having them taken away, cared for by other people, which could affect that bond, could affect the patient’s ability or confidence in being able to look after that child as a parent. It’s such a critical time for anybody, so the fact that someone could be having a mental health crisis whilst having this critical time as well and then being treated in this way, of being ferried around, shipped about, not being told what’s happening, the family not being told and, to this day, still not really knowing what happened, I don’t know how we could get to a state – I don’t know how we can get to this state of affairs –
The Chair: Yes.
Lydia Fraser-Ward: – of being. How could a hospital or that’s responsible for a patient not know where they have gone, not know what happened to them just because they have gone to a different geographic area? It doesn’t suddenly not become their responsibility any more.
The Chair: Yes.
Lydia Fraser-Ward: Pippa lived in Essex, she was an Essex resident, she was the responsibility of the mental health and the medical services in her area. Because they didn’t have enough beds, they didn’t have a provision to support her in any way, they are having to ship her off somewhere else and ask somebody else, “Please take care of this person for us”.
The Chair: Yes.
Lydia Fraser-Ward: But the least they could do is stay on top of – keep in touch with and find out what’s happening because she is their responsibility. At the end of the day, she is still the responsibility of EPUT, whether she is being treated by them or not.
The Chair: Yes.
Lydia Fraser-Ward: And they should have been making sure that she was being taken care of, making sure that she was safe, and asking these important questions. I know resources are tight but you don’t just wash your hands of someone when you send them off to another hospital, in my opinion.
The Chair: As you say later in your statement, the other factor in this is that it’s very difficult to see, I think you describe it, as Pippa being bounced around –
Lydia Fraser-Ward: Mm-hm.
The Chair: – between these different units – because, after Staffordshire, we will come on to Pippa staying in a mother and baby unit in Winchester – it is difficult to see, I think is the way that you describe it, how this could be anything other than detrimental to her recovery –
Lydia Fraser-Ward: Absolutely.
The Chair: – at a stage like that in her life.
Lydia Fraser-Ward: Yes.
The Chair: All of these transitions and new environments each time and a lack of certainty being just one of the many problems.
Lydia Fraser-Ward: I mean, I would just ask the Chair and anyone listening, imagine you have just had a baby and you are well, you are well, and you have had a baby, you have got this young child to look after, and you are being asked to move to a completely strange place and look after them there, and then two days later you are being asked to pack up all your things and move to another place and look after your baby there, and you have not slept and you’ve been awake all night and you are moving, and you are moving, and you are somewhere else, and you are far away from your friends, you are far away from your family, and that’s if you are well: how hard would that be?
Imagine now doing that where you can’t trust your own memories, your own thoughts, your own ability, you lack complete confidence in yourself as a parent, where you are terrified that your baby might be taken away from you if you do the wrong thing, if you say the wrong thing, you behave in the wrong way. It is only natural for someone to then start masking and say, “I am fine, I can take care of it, I can look after them”.
I can’t imagine what she went through. I will never be able to imagine exactly what she went through but it must have been so terribly, terribly frightening and terribly hard for her. And it is so deeply unfair –
The Chair: Yes.
Lydia Fraser-Ward: – that they felt that the best way to treat someone in this state was to continually just send them off somewhere else so they could find a bed, wherever that might be.
The Chair: Yes.
Lydia Fraser-Ward: It wasn’t taken into consideration how that distance would affect someone, how that constant transience would affect someone’s wellbeing.
The Chair: Yes.
Lydia Fraser-Ward: I mean, it was only going to make it worse. I understand that there are limitations to resources and there may not – there are not enough beds, we all know there are not enough beds. There need to be more beds, for goodness sake, we are begging you for more beds, more services, more support.
But, equally, would she have not been better just not in an MBU but in an acute ward somewhere where she could have kept the baby with her? Surely that would have been better.
The Chair: And possibly locally, I think, is what you suggest?
Lydia Fraser-Ward: She could have been near her husband, near her other child, near her home where she was around things that she recognised.
The Chair: Yes.
Lydia Fraser-Ward: I mean, in some ways she was actually quite lucky with her admission to Staffordshire because she appears to have had a good stay there of about six weeks. She did make a recovery of sorts. She did improve and get better.
The Chair: Yes.
Lydia Fraser-Ward: The mania stopped – well, she says – we feel – there is a reference here that she was in mania for those six weeks in Staffordshire and I had no contact with her there, I was discouraged from contacting her, I certainly wasn’t given any information about how to contact her, I wasn’t even sure exactly where she was. But she did make a recovery and in her diaries she refers to – it’s a very interesting reference in the back of her diary where she talks about when she is better all the books she is going to write, all the things she is going to do, and one of the things she wanted to was she wanted to write an account or a book about her experience of this and she wanted to do a – she wanted to make a comparison between her experience in Broomfield versus her experience in Staffordshire –
The Chair: Yes.
Lydia Fraser-Ward: – one versus the other, and how one is a good experience and how one is an awful experience, that being the one in the Essex, in Broomfield, even though she was only there that one night, it was so bad she actually wanted to write. Can you imagine having an experience that was so bad you wanted to write a book about it afterwards?
The Chair: I think she said, did she, that in comparison, one of the things that you found in her notes was that she wanted to nominate Staffordshire for an award –
Lydia Fraser-Ward: Yes.
The Chair: – because the contrast or, in part, the contrast was so
stark between –
Lydia Fraser-Ward: Yes.
The Chair: – it was less than a day, actually, I think –
Lydia Fraser-Ward: Yes.
The Chair: – that she was at Broomfield and the treatment she
received at Staffordshire where, as you say in your
witness statement, she experienced some peaks and
troughs in her recovery –
Lydia Fraser-Ward: Mm-hm.
The Chair: – but she was working her way towards a recovery –
Lydia Fraser-Ward: Yes.
The Chair: – in that time on the unit in Staffordshire?
Lydia Fraser-Ward: Yes.
Ms Troup: Lydia, I am being advised, if this is all right
with you, that it might be time for us to take a short
break, I think of around about 10 minutes.
Lydia Fraser-Ward: Sure, okay.
Ms Troup: If you are also content with that, Chair?
The Chair: Yes, thank you very much.
Lydia Fraser-Ward: Thank you.
(12.11 pm)
(A short break)
(12.37 pm)
The Chair: Ms Troup.
Ms Troup: Lydia, we were talking before the break about Pippa’s time on the unit in Staffordshire and before I move on to her discharge from there, there is one matter I wanted to note you tell us about, and this is something you have learned about from Pippa’s diary entries from her team in Staffordshire, which is that she refers to an advocate who happened to have some sort of oversight and support role in relation to Pippa’s care and that that was something, as far as you could see, from her diaries that she appeared to value very much indeed.
Lydia Fraser-Ward: Yes, that is right. She has entries in her diary when she has clearly had some sort of induction at Staffordshire because she has made lots of notes about what to expect and when there are going to be reviews, when there are going to be appointments, and then there is a reference to – she has the right to have an advocate who will speak on her behalf, which sounds brilliant. And later there are references to this person’s name. This person’s name happens be the same as her best friend’s name as well.
Ms Troup: I see.
Lydia Fraser-Ward: So there’s some confusion sometimes whether she is referring to this person, whether she’s referring to this advocate or whether she’s referring to her best friend.
Ms Troup: Yes.
Lydia Fraser-Ward: But I think, when I’m looking through, it appears that these are probably references to the advocate where she’s making lots of positive comments about having someone on her side to support her, to stand up for her and to back her up and what she is asking for.
Ms Troup: Yes, and as far as you are aware, there is no other reference to someone in that role or any kind of advocate at any other time during Pippa’s treatment?
Lydia Fraser-Ward: Not that I’m aware of, there’s no reference to it and she doesn’t make reference to anyone else supporting her.
Ms Troup: Lydia, I understand that Pippa was discharged from the unit in Staffordshire on a date in August 2016, the exact date is not all together clear, and that you saw her, she came to visit you at home, on Saturday, 21 August. You found her, at that time – I am so sorry, if you are following, I’m on page 20 of your witness statement at the top of the page.
Lydia Fraser-Ward: Thank you. Okay. Yes.
Ms Troup: As I understand it, on that date, you found her demeanour, you have described this as neutral and flat?
Lydia Fraser-Ward: That’s right, she was. It was a bit of an odd day, I – before I had my children, I used to run outdoor events and I’d had a really big event that week and a friend was over helping me deconstruct all the bits and pieces from that event in my garden. This friend was in the garden taking this project apart and I was sort of saying to them, “Can we hurry up, can we hurry up because my sister is due over and I don’t know how she is going to be, I haven’t seen her since she left hospital and I just don’t want there to be anything chaotic going on”. And there was a lot of mess everywhere, wires and cables and things.
And, in the end, it did cross over and I remember her being in garden, watching what was happening and us putting things away, and she was – she was just very neutral and flat and quiet, not upset, not agitated or anything, just sort of a quiet version of herself.
Ms Troup: Yes. We know from the records that by 6 October, in fact Pippa had again had been informally admitted to an acute mental health ward in Chelmsford. At the time, you were not aware of that admission; is that right?
Lydia Fraser-Ward: I only found out about anything happening in Essex much later.
Ms Troup: Much later –
Lydia Fraser-Ward: Yes.
Ms Troup: – I understand. As far as you are aware, in the period after Pippa had been discharged into the community from the unit in Staffordshire, there appear to be no community treatments or support of any kind in place?
Lydia Fraser-Ward: Well, not that I am aware of.
Ms Troup: Yes.
Lydia Fraser-Ward: I’m sorry, if you are wondering what I am flicking through here, I sort of made a timeline of events because, basically, this is how little information I had. I had so little information about Pippa’s treatment that I have had to piece together what happened to her from medical reports, from her diaries, from people’s memories, from my own diaries –
Ms Troup: Yes.
Lydia Fraser-Ward: – and try and piece together what, what actually happened to her and when because it was – there was lots of contradictory information as well and I don’t know what information I can trust to be the correct information, and it’s very – I think it is very sad that I am in a situation where I don’t really know exactly what happened to her and when, and that I am having to basically do detective work to try and work out exactly when did she leave this place and when did she go to that place, and there doesn’t seem to be any kind of coherent record.
Ms Troup: Yes.
Lydia Fraser-Ward: The only record that we have really been able to work from is the report, which I’m sure we’ll come onto, which was prepared for her inquest.
Ms Troup: Yes.
Lydia Fraser-Ward: And obviously that has been prepared by one NHS Trust, the one overseeing Winchester.
Ms Troup: That was Southern Health?
Lydia Fraser-Ward: That’s right, and so therefore they don’t have firsthand information on all of her treatment.
Ms Troup: No.
Lydia Fraser-Ward: They are trying to piece together bits of information from other trusts and other people’s recollections and, unfortunately, that report itself is riddled with inaccuracies, it has some errors here and there, so you know this was a few years ago now, I am – we are all sort of going back to our recollections of what happened.
Ms Troup: Yes.
Lydia Fraser-Ward: Did she come here then or was she here then and how was she feeling on this – I am tying up the records of what we remember happening with what she is writing in her diaries on these dates and trying to see what sort of mental state was she actually in at these times, rather than just trying to see it purely from my own perspective, as best as I can anyway.
Ms Troup: I understand, and I am keenly aware that you are trying very hard it piece events together from different
sources, some of which you’re not even clear whether or
not they might be accurate. I think it is, nonetheless,
incredibly useful to have your impressions and your
recollections of the time.
I know that you tell us you were not aware that
I think between 6 October 2016 and the 11th, Pippa had
been admitted to an acute mental health ward.
Lydia Fraser-Ward: Of October, did you say?
Ms Troup: Yes, October 2016.
Lydia Fraser-Ward: In Chelmsford?
Ms Troup: In Chelmsford.
Lydia Fraser-Ward: This is something I found out very recently, I didn’t
know about and, again, it’s sort of been pieced together
from bits of pieces of information and people’s
recollections but, yes, apparently, she did stay –
Ms Troup: Yes.
Lydia Fraser-Ward: – it’s compounded by the fact that we had made
arrangements to meet –
Ms Troup: Yes.
Lydia Fraser-Ward: – and she had sent me a text message the day before
I was due to meet her saying, “I can’t meet with you
because I have a hospital appointment”. That’s what she
had sent me. It turns out she was actually already in
hospital receiving treatment?
Ms Troup: Yes.
Lydia Fraser-Ward: So she wasn’t telling me that she was in hospital receiving treatment at the time. Again, probably to protect me and to not worry me because she didn’t want me to be worrying about her.
Ms Troup: Yes.
Lydia Fraser-Ward: So she put it that way, like, can we re-arrange for next week. She was expecting to be back home, so she wasn’t anticipating to be staying very long in that unit either.
Ms Troup: Yes, I understand. You have no records relating to that stay in the acute ward in Chelmsford?
Lydia Fraser-Ward: No, nothing.
Ms Troup: But did then see Pippa when she returned home because you visited her at home on 13 October?
Lydia Fraser-Ward: Yes.
Ms Troup: You tell us in your witness statement that, at that time, she did appear noticeably unwell, you were able to see her agitation?
Lydia Fraser-Ward: I had never seen her that unwell before, ever. So the plan was that I was going to come and visit and, me being me, thought I know, I will come, I will bring a big bag of food and I will cook her a nice lunch, I will make her some sausages and mash, or something like that, and I will make a nice lunch for her, so she doesn’t have to worry about food, and I’ll just help out and I will be helpful. I was always going to her house and, I don’t know, tidying or cleaning or doing something she probably didn’t want me to do, trying to make myself useful. And I sort of bowl in there and I’d brought all this food, and she is very tense and she is very agitated and both the children were definitely – the eldest child was at school during the day, the baby was at home –
Ms Troup: Yes.
Lydia Fraser-Ward: – I remember making lunch for her, and she got very upset because I had scratched her frying pan, and she was really very, very, very upset about this, which is not like her at all, and I felt terribly guilty. I thought, “Oh, no, I have made things worse, I wanted to make a meal and I have ruined it”, and I was like, “I will buy you another one, I will get you another one it is going to be okay”.
And what would happen is I would be in the front room, like, with the baby, holding the baby, playing with the baby, and I would hear her going into the kitchen, shutting the door and saying to her husband “Don’t want to be here, don’t want to be here”. And at the time I thought, “Gosh, she doesn’t want me to be here, I should go, I am making things worse, I should go”. And then later, I sort of reflected that she was actually probably saying to him, “I don’t want to be here, I don’t want to be here”, because she had been also saying to him a lot at the time how unhappy she was and –
Ms Troup: Yes.
Lydia Fraser-Ward: – how she wanted to die and she was making lots of comments like this. But I, at the time, didn’t know that that was happening. I just sort of rolled in, saw that she was a bit tense –
Ms Troup: Yes.
Lydia Fraser-Ward: – but she would sort of go off, you – I could hear her getting agitated and upset and saying things like that and she would come in and she would be like “Okay, does anyone want a cup of tea”, and then she would be sort of trying to put on a brave face again. And I’d be like “We are all right, we are okay, everything’s okay”.
Ms Troup: Yes, and that feeds into all that you have told us about had her ability either to protect you or because she was so determined to be well –
Lydia Fraser-Ward: Yes.
Ms Troup: – and to depend on herself to become well, to mask in this way –
Lydia Fraser-Ward: Yes.
Ms Troup: – and to get herself back into a position where she was upbeat but, in fact, as you have said, she was more unwell than you had ever seen her?
Lydia Fraser-Ward: Yes, definitely, there was a point in the day where the baby was crying and she didn’t know what to do, she just sort of sat on the sofa and I said, “Do you want to hold the baby?” And she said, “I don’t know what to do”.
Ms Troup: You say in your witness statement that she looked almost frightened?
Lydia Fraser-Ward: Yes.
Ms Troup: Yes.
Lydia Fraser-Ward: Not like that she would hurt the baby, or anything, but she just sort of looked lost –
Ms Troup: Yes.
Lydia Fraser-Ward: – and our mother was there and I was like – you know, she was about to take the baby, and I said, “I am sure Pippa knows what to do, she’s already had a child”, and Pippa just looked completely lost and so our mother took care the baby, which was the right thing to do, obviously.
Ms Troup: Yes.
Lydia Fraser-Ward: But I was like, gosh, you know, she didn’t even know how – like, I was surprised that she didn’t – not want to hold the baby, but she felt almost like she couldn’t, it was beyond her, like she was going to do it incorrectly or she was somehow going to get it wrong and she just looked lost, overwhelmed.
Ms Troup: Yes.
Lydia Fraser-Ward: So she wasn’t crying and she wasn’t weeping and she wasn’t being manic, she just looked like a person who had sort of almost given up, do you know what I mean?
Ms Troup: Yes. You now understand that later that evening, in fact, Pippa took an overdose and that two days after that, I think on 15 October, made an attempt to cut her wrists?
Lydia Fraser-Ward: So that day that I went to visit was the last time I saw Pippa alive in person.
Ms Troup: Yes.
Lydia Fraser-Ward: So I – just to step back once, if that’s okay. So I said I was going to go home and I usually used to walk to the train station. Her husband very kindly offered to drive me the short distance, and I said, “You don’t need to”, but I think we were worried I was going to miss a train and they weren’t that frequent, and she asked if she could come in the car with us, which she never did. She was like, “Bye” – usually, “Bye, see you next time”.
“Can I come too?” I was like “Absolutely”.
So I think, if I remember rightly, our mother stayed at home with the baby, she got in the car, I got in the car and her husband drove us to the station, and when I got out, she gave me this huge hug and it’s not that we weren’t affectionate but it was quite unexpected. She gave me this huge deep hug and then she almost sort of begged me, “Will you come back, come back”, and it was about a week or two’s time, on this exact date, and I was like “Well, I have to work that day”, and she was like, “No, but please, can you try, can you try and be here on this date?” I was like, “Well, okay, I will try and clear my diary and come, if you really want me to be here, I will, I will come”.
And then I got on the train. That was the last time I saw her.
Ms Troup: Yes.
Lydia Fraser-Ward: Then as soon as they got home, her husband, I think, went in the other room to check on the baby and then he came in and discovered her taking some paracetamol.
Ms Troup: Yes.
Lydia Fraser-Ward: She is allergic to paracetamol anyway, and he discovered her after she’d taken maybe two or three, I think, and her plan was to take [I/S] or something. That was her plan, anyway.
Ms Troup: Yes.
Lydia Fraser-Ward: Which was very upsetting for me to hear –
Ms Troup: Of course.
Lydia Fraser-Ward: – obviously. Anyway, because you are thinking “What on earth?” I knew that she was clearly unwell but the way
that she was speaking to me when we said goodbye, she
wanted me to believe we were going to meet again.
Ms Troup: Yes.
Lydia Fraser-Ward: “Make this day free, we will meet again, I will see you
then”, with plans in her head to kill herself. So,
obviously, when I got the news the next day, I think,
when I spoke on the phone with my mother, she told me
what happened, I was just – I was like, “But she just
said to me, we were going to meet”.
Ms Troup: Yes.
Lydia Fraser-Ward: And knowing that she was saying that fully intending to
take her own life is quite hard to comprehend –
Ms Troup: Of course.
Lydia Fraser-Ward: – as someone who isn’t unwell, like, why would she say
that, why would she make plans, why would she get so
upset about this little thing if she was planning to
die? Do you know what I mean?
Ms Troup: I do.
Lydia Fraser-Ward: It feels very contradictory to rational thinking.
Ms Troup: Yes, which of course it is. Yes, and you understand
that then on 15 October she was admitted to A&E at
Broomfield again, having deliberately cut her wrists?
Lydia Fraser-Ward: I think she was attempting so she had – I don’t know
fully exactly how much she had hurt herself but she had
had a serrated knife in her hand –
Ms Troup: I see.
Lydia Fraser-Ward: – and was planning to impulsively cut her wrists. So I don’t know if she had actually managed to hurt herself physically or not.
Ms Troup: Yes.
Lydia Fraser-Ward: But they had taken her there on that basis, that she had attempted to self-harm.
Ms Troup: I understand. And from Broomfield, attempts were again made to find a place for Pippa at a local mother and baby unit and, again, no places were available?
Lydia Fraser-Ward: No beds, no beds, yes.
Ms Troup: Arrangements were then made for her to be transferred to a mother and baby unit in Winchester, and that is the last inpatient facility that Pippa was transferred to and it is for that reason, as you understand it, that the investigation report was later carried out by the Trust that oversees that unit, Southern Health?
Lydia Fraser-Ward: Yes, I mean, from what I know, from having looked at the report drawn up by Southern Health, that when she was admitted, which I believe which was on the 16th, she had made a request to be moved to an acute ward –
Ms Troup: Yes.
Lydia Fraser-Ward: – but she was denied. She said she didn’t feel she could care for her baby and that’s why she wanted to go on an acute ward, and they said, “No, you can’t, you have to stay on the MBU”.
Ms Troup: I think what you record in your witness statement is that, on three or four occasions, within the first three days of her admission to Winchester, she made that request to be transferred to an acute ward?
Lydia Fraser-Ward: Yes.
Ms Troup: On each occasion, that request was denied?
Lydia Fraser-Ward: That’s right.
Ms Troup: The answer being a form of, “Let’s wait and see”?
Lydia Fraser-Ward: Yes, that was often the answer to everything, was “Let’s wait and see”, not just at Winchester but, you know – sorry to step back but, the Chelmsford acute mental health ward that she stayed in a few days prior, when we look at this in dates, so she was – she was in this acute ward in Chelmsford on 10 October.
Ms Troup: Yes.
Lydia Fraser-Ward: In fact, she was there on the 8th to the 10th, I think.
Ms Troup: Yes.
Lydia Fraser-Ward: Again, why is she being discharged home? Why is she being discharged home? So she asked to go there, then when she arrived she changed her mind and she wanted to go home but she’d already been admitted and they were like, “Let’s stay, let’s see, let’s see how you do, let’s see how you do”.
Ms Troup: Yes.
Lydia Fraser-Ward: She is being discharged and within, you know, a day she is making a suicide attempt. Then the following day, she has been found with a knife then, the following day she has been found with another knife.
Ms Troup: Yes.
Lydia Fraser-Ward: How can someone who is making all these attempts at self-harm and suicide be okay to be discharged only a day before from the Chelmsford mental health ward.
Ms Troup: Yes.
Lydia Fraser-Ward: How could she be fine? How could they assume she is safe and fine if she is making multiple suicide attempts?
The Chair: Can I just ask, when you refer to her asking to be referred to an acute ward, by that you mean an acute ward in Essex, she wanted to come home, or do you think she wanted just to go on to an acute ward not a mother and baby unit?
Lydia Fraser-Ward: I think she just wanted to go on an acute ward. This is when she arrived at Winchester, so this is just from their report, so it is unclear, if I am honest. It is unclear, it just says she makes a reference – a request to go on an acute ward, so I assume that means within the hospital in Winchester, rather than staying on the mother and baby unit because, basically, what she must have been saying to them is, “I can’t care for my baby, I don’t feel well enough to look after my baby, can I not go in a ward without the baby because I can’t – I can’t” – if you’re in a mother and baby unit, you are basically still in a room with your baby, caring for your baby next to you, and they are sort of checking in on you and making sure you are okay. It’s not like someone is caring for your baby for you. You are still looking after the baby, you just happen to be in a hospital environment. But, ultimately, you are still the primary caregiver.
And I think what she must have been saying to them, “I can’t take care of the baby, I need to be in an acute ward where someone is taking care of me”, and they kept saying, “No, you can’t go there, you have to look after the baby yourself”.
Ms Troup: Yes. That’s very helpful. One of the things that you note is that, when she was admitted and in the early days of her admission to the unit in Winchester, Pippa was seen as sufficiently high risk that she was on five-minute observations. She repeatedly expressed, as you have said, her wish to be transferred and that she felt she was unable to take care of the baby.
Lydia Fraser-Ward: Mm-hm.
Ms Troup: We also see – and these are matters that you have learnt about from the investigation report – that by 19 October, having expressed suicidal thoughts to staff, Pippa was found with a dressing gown cord tied around her neck?
Lydia Fraser-Ward: Loosely, yes. Loosely around her neck.
Ms Troup: Loosely.
Lydia Fraser-Ward: That’s again – this is purely from the report drawn up by Southern Health.
Ms Troup: I understand.
Lydia Fraser-Ward: So it is as accurate as their report, but what it states is that having been – so she was admitted approximately on the 16th, she had made multiple requests to be moved to an acute ward that day and on the 17th. On the 18th, she is expressing suicidal thoughts and she is having a review with a consultant psychiatrist. She states that she would like to be dead, she can’t see herself getting any better and she can’t take any more. She requests a transfer once again to an acute mental health ward –
Ms Troup: Yes.
Lydia Fraser-Ward: – and the request is denied. And then, on the 19th, she is found in her – she is observed, let’s say, with this dressing gown belt tied loosely around her neck.
Ms Troup: Yes, and Lydia, is this right, what we also know from that report is that, just seven days later on 26 October, Pippa herself, despite that event on the
19th, approached the staff office on the unit and handed
in her dressing gown cord –
Lydia Fraser-Ward: Yes.
Ms Troup: – saying that she had again made an attempt or at least
put it around her neck?
Lydia Fraser-Ward: She had made a genuine attempt to kill herself, so she
made multiple attempts to strangle herself with the same
cord that she had been observed with a few days before,
as you say –
Ms Troup: Yes.
Lydia Fraser-Ward: – and that she had tried to – using a ligature point
on the cot bed, tried to take her own life and failed.
Ms Troup: Yes.
Lydia Fraser-Ward: Yes, as you say, she approached the office in floods of
tears with the cord saying, “Please, take this away from
me, I have tried to take my own life, you know, please”.
Ms Troup: Yes.
Lydia Fraser-Ward: So why she had been left with this ligature at all, why
should she even have been allowed into the hospital with
the high-risk item of that nature.
Ms Troup: Yes.
Lydia Fraser-Ward: I mean, I would assume that high-risk patients would
have their belongings checked for anything that’s high
risk before – once they are admitted. So she’s got
a dressing gown, she’s got a long tie, which is obviously an obvious ligature risk, it’s not been taken off her, she is then observed having it tied around her neck, it is still not taken off her. A few days later, she tries to strangle herself with it and she hands it into the office saying, “Please take this away from me”.
Ms Troup: Yes.
Lydia Fraser-Ward: That’s the only reason. No one observed her trying to take other own life, no one noticed her taking her own life. She had to come in, volunteer it and she had all these red marks around her neck, apparently, and she was crying and she begged them to take it away from her.
Ms Troup: Yes. I understand that, after that, in a one-to-one meeting with the nurse, Pippa described what you say in your witness statement, a general sense of hopelessness, being afraid of leaving hospital –
Lydia Fraser-Ward: (Witness nodded)
Ms Troup: – being unable to care for the baby and her five year old at the time, and that when she was asked – because there was a plan in place at the time for Pippa to go on weekend leave or sort of overnight leave –
Lydia Fraser-Ward: Yes.
Ms Troup: – to go with her husband for the baby’s immunisation appointments?
Lydia Fraser-Ward: That’s right.
Ms Troup: So, after that event we have just discussed, where Pippa herself handed in this dressing gown cord, she had a one-to-one with the nurse, as I understand it, who asked her if she considered that she could keep herself safe on leave and that Pippa’s answer was “I think so”?
Lydia Fraser-Ward: Yes. I mean, just so we don’t skip over it as well –
Ms Troup: Yes, of course?
Lydia Fraser-Ward: – in between – in between the cord being found loosely around her neck and the second ligature attempt, she had in between those few days also been asking staff to give her paracetamol –
Ms Troup: Yes.
Lydia Fraser-Ward: – which she is allergic to and which she had tried to take on overdose of, only a week or so before, and that wasn’t sort of seen as an act of self-harm. They had to sort of check her notes, and she was saying, “I am not allergic to it any more, I am not allergic to it any more”, and no one seemed to flag up, you know, why is she asking for these painkillers which she is allergic to.
And it is frustrating to read this report – if you look through this Southern report for the inquest, it will heavily focus on “She’s having a really good day today, she’s recovering today, she’s doing great, she seems to be on the mend”, because for 24 hours she hasn’t expressed suicidal thoughts, therefore she must be better, she must be well now, she must be improving. They think a 48-period of not expressing the wish to kill yourself means that you are improved, you are making a recovery.
Ms Troup: Yes, and as you say – sorry, I don’t mean to interrupt – you say in other parts of your witness statement that, in fact, sometimes those extremes of mood would fluctuate three or four times within a day?
Lydia Fraser-Ward: Yes, yes. Well, so for example, on this day when she was found with the cord tied around her neck but she hadn’t attempted to hurt herself, that we know of –
Ms Troup: Yes.
Lydia Fraser-Ward: – which was on 19 October, she asked for a short period of off-site leave with her husband.
Ms Troup: Yes.
Lydia Fraser-Ward: And it was agreed, it was approved. So she had been seen with a ligature around her neck and says, “Can I go out for a walk with my husband?”
“Fine, go, go, have a walk around”. There doesn’t seem to be any – if there are protocols as to how to manage this, it’s unclear or inconsistent what they are.
Ms Troup: Yes.
Lydia Fraser-Ward: How do you assess the risk of someone to themselves or others? If someone has attempted to kill themselves 12 hours before, are they now no longer a risk, or if it is 24 hours before are they no longer a risk, or a week, or a month?
How do you know when someone is no longer a risk to themselves and others? And, obviously, it’s a case-by-case basis but there doesn’t appear, in my sister’s case, to be any sort of consistent risk assessment process, and I know that risk assessments have come up a lot in this Inquiry and we are sort of looking at how effective they are, how complicated they are –
Ms Troup: Yes.
Lydia Fraser-Ward: – and it is difficult, I’m sure, very difficult. You can’t have a one size fits all. But when I am looking through the evidence of this Inquiry, which is looking at risk assessments, of which there are hundreds of pages about risk assessments and lots of guidance and lots of recommendations, but ultimately when you get down to the actual risk assessments themselves, the actual tools, they are fairly basic, from what I could tell.
It’s a sort of – the suicide high-risk assessment is a series of a few questions sort of to assess how are you feeling today, sort of out of this score? And the questioning that seems to be made of my sister at this time is always, “Do you feel you can keep yourself safe?” That generally was the question, “Can you keep yourself safe, yes or no?”
Ms Troup: Yes.
Lydia Fraser-Ward: You know, and if she can answer yes to that fine, go out, do something, do whatever you like. Go, you know, or maybe let’s stagger, you know, your exposure so that you’re allowed to walk around the grounds, then maybe you are allowed to go into town and then maybe you’re allowed – and I understand that staggered approach makes sense. It’s logical. But it doesn’t seem to take into account when a patient then will have a dip or a low.
Ms Troup: Yes.
Lydia Fraser-Ward: So let’s go back and accept that you have had a lower period and start again. It seems to say, “Oh, you had a little blip, but it’s fine, you are better today. So let’s continue doing what we were doing. Let’s continue progressing forward”.
Ms Troup: Yes.
Lydia Fraser-Ward: Let’s set a date for when you will be “well” and let’s try and get you out of hospital by this date because that’s how human beings work. And unfortunately it just isn’t. People don’t get well according to a timetable or a schedule.
Ms Troup: No.
Lydia Fraser-Ward: You have to sort of see. I mean, you know, Pippa had highs and lows because of, you know, environmental factors as well.
Ms Troup: Yes.
Lydia Fraser-Ward: She was having a couple of days where she was doing better. Then the date of her baby’s immunisation changed and got pushed back a couple of days and she suddenly went downhill. She’d suddenly become very depressed because she thought she was going home and now she has to wait an extra couple of days. So suddenly she is very, very down again having a low period.
Ms Troup: Yes.
Lydia Fraser-Ward: And having a – and then asking for paracetamol from the staff because she can’t take it any more because she was planning to go home and now it’s been delayed.
How can you keep the same risk assessment from a week ago or two weeks ago in place for a person that’s now had this new information and this new news.
Ms Troup: Yes, I understand. I think this feeds into one of the matters that you have set out in the latter part of your witness statement about recommendations for change, where you talk about a need for standardisation of risk assessment?
Lydia Fraser-Ward: Well, certainly a consistency.
Ms Troup: Yes.
Lydia Fraser-Ward: Like I said, human beings are all unique. It’s very hard to make a standard risk assessment for people, I am sure –
Ms Troup: Yes.
Lydia Fraser-Ward: – and I’m not a clinician. But it seems – I cannot fathom or comprehend the current risk assessment –
Ms Troup: Yes.
Lydia Fraser-Ward: – process because at the moment it seems to be just a series of a few questions of: How are you feeling? Can you rate how you are feeling? Do you feel you can keep yourself safe yes or no? And maybe this has indeed changed. But it doesn’t seem to take into account all the other factors –
Ms Troup: Yes.
Lydia Fraser-Ward: – such as: Has the patient recently had some news? Has the patient the enter recently expressed these thoughts in a group therapy session?
Ms Troup: Yes.
Lydia Fraser-Ward: Has the patient been, I don’t know, eating normally? And it may be these conditions are considered but it doesn’t seem obvious to me as an outsider looking at the risk assessments that these are taken into account.
So there doesn’t seem – with the risk assessments I’ve seen so far, and apologies, Chair, if I have missed this within all the evidence that’s been provided because there’s so much of it, but when locking through some of the risk assessment guidance that was provided by EPUT I couldn’t see, and forgive me if I have missed this, I couldn’t see a risk assessment tool which used a risk matrix.
Ms Troup: Yes.
Lydia Fraser-Ward: You know, where you would look at not just the severity of risk but the probability and – as you would with anything else. In any other industry when you are doing a risk assessment you would do a calculation matrix. It’s not just how severe that risk is, but how likely it is.
Ms Troup: Yes.
Lydia Fraser-Ward: And you are calculating the likelihood of this person harming themselves is now in this sort of zone because the probability has changed.
Ms Troup: Yes.
Lydia Fraser-Ward: The severity is the same, but the probability has now changed. And surely that should be an ongoing – risk assessments should be an ongoing process throughout a patient’s treatment because they will be going through highs and lows and things will change and parameters will change and circumstances will change.
Ms Troup: Yes.
Lydia Fraser-Ward: And the feeling I got, the feeling I get from reading through Pippa’s reports and from hearing from some of the other Core Participants, and from hearing evidence from EPUT themselves, it feels very much that when a patient is admitted – and apologies if I have misunderstood this – but it feels like when a patient is admitted a plan is made that this patient will have this treatment and will get by this date and let’s keep working towards getting this patient better by this date.
Ms Troup: Yes.
Lydia Fraser-Ward: And even if they have hiccups and ups and downs, we will continue to target because we need to clear this bed for the next patient.
Ms Troup: Yes. You have described those as arbitrary targets and you have said that you are very interested to try to understand why that is seen as some sort of acceptable model of care, to set targets in that way?
Lydia Fraser-Ward: Well, I think I know why. It’s due to limited resources –
Ms Troup: Yes.
Lydia Fraser-Ward: – limited beds, limited staff. We all know this. There is not enough money, there is not enough staff, there’s not enough beds. Let’s move people in and out.
If somebody is well enough to go home, let’s get them home.
Ms Troup: Yes.
Lydia Fraser-Ward: If they are home, they are going to do better, they are going to do better. But I don’t understand where that attitude has come from, like, as if, if someone is at home, they will make a more rapid improvement.
I am sure with some patients that is the case.
Ms Troup: Yes.
Lydia Fraser-Ward: Some patients will do better at home, but not all and it is almost as if, if we can get someone home, they are better.
Ms Troup: Yes.
Lydia Fraser-Ward: They have made a recovery, they are doing well. Keeping them in hospital may not be improving their chance of getting better. And I just think that seems rather generalised across the board for everyone.
Ms Troup: Yes.
Lydia Fraser-Ward: It did seem that some of the evidence I heard from expert witnesses and from EPUT was very much about: we found that people staying in hospital longer doesn’t necessarily mean better outcomes.
But people are individuals, and this sort of need to push people through their treatment and see the recovery as quickly as possible I don’t believe is in patients’ best interests. I believe that we should be taking it on a case-by-case basis and saying, you know, “Actually this patient is struggling. This patient is not getting better. What we are doing does not appear to be working effectively. Let’s try another course. Let’s change this plan and not keep to this target date”.
Ms Troup: Yes.
Lydia Fraser-Ward: I recall a comment being made by an EPUT representative of, “Oh, well, you know, if we don’t set a target date they just stay, they just don’t go. They stay in hospital, they don’t leave and we don’t know how long they’re going to be here for”.
And it’s like, well, maybe that’s what that patient needs is not the pressure to be better by a certain date. Maybe we need to give a patient time to actually recover.
Ms Troup: And assess it on a case-by-case basis as you say?
Lydia Fraser-Ward: Exactly, yes. And it does sometimes feel that, you know, why is – how can it be less expensive to continually admit and discharge a patient into multiple different hospitals, multiple different teams and different staff? How is that saving money?
How is sending Pippa to Staffordshire, to Chelmsford, to Winchester to possibly Nottingham, back home, into hospital, back home again, how is that more affordable than perhaps just sending her to an MBU where she could get better in her own time –
Ms Troup: Yes.
Lydia Fraser-Ward: – where the staff there get to actually know her and know her condition and can tell, because they know her, that she is in fact actually improving.
Ms Troup: Yes.
Lydia Fraser-Ward: And is it too much to ask or expect that that unit can be a short distance from a person’s home and not 200 or 300 miles or a three or four-hour drive? Because that does make a difference. Being far from home does limit your recovery and it delays your recovery.
Ms Troup: Yes.
Lydia Fraser-Ward: And I don’t – I don’t think you need to be a clinician to know that.
Ms Troup: Thank you. In summary, in spite of that act of self-harm that we have discussed which took place on 26 October, and although the duty doctor did call Pippa’s husband to tell him about that, the decision was made that her home leave would go ahead as planned?
Lydia Fraser-Ward: It would be delayed, I think, by a day.
Ms Troup: Yes.
Lydia Fraser-Ward: So the plan was that she was going to go home and because she had attempted to end her life, they thought let’s keep her in for a night and see how she is doing tomorrow.
Ms Troup: Yes. That evening, on 26 October, staff observed that
Pippa appeared to have become physically unwell. There
was some sort of D&V bug on the ward –
Lydia Fraser-Ward: Yes.
Ms Troup: – that Pippa appeared to have contracted?
Lydia Fraser-Ward: That’s right. So she caught – unfortunately caught
a really nasty virus or some sort of vomiting bug whilst
off of the ward. There had been a staff member off at
the time with a similar virus.
Ms Troup: Yes.
Lydia Fraser-Ward: And so it’s assumed that something was going around. So
she had become physically unwell and then, of course,
because she was physically unwell, she was then put into
isolation –
Ms Troup: Yes.
Lydia Fraser-Ward: – which only exacerbated her anxiety and desperation to
go home.
Ms Troup: Of course. So she was asked to stay in her room –
Lydia Fraser-Ward: Yes.
Ms Troup: – so as not to infect the rest of the ward?
Lydia Fraser-Ward: That’s right.
Ms Troup: In the background, she had been saying – and you have
seen this in the records – that she desperately missed
her family –
Lydia Fraser-Ward: (Witness nodded)
Ms Troup: – desperately wanted to be at home?
Lydia Fraser-Ward: Yes.
Ms Troup: I think you have noted, in relation to the discussion we
had about this question that is asked in a risk
assessment, “Do you feel able to keep yourself safe?”
the truth is that, as you see it, Pippa probably felt
terribly conflicted in giving an answer to that
question?
Lydia Fraser-Ward: Yes.
Ms Troup: Because she desperately wanted to be at home and wanted
the answer to be, “Yes” –
Lydia Fraser-Ward: Yes.
Ms Troup: – “I feel able to keep myself safe”. And I think part
of what you’re saying is that the evidence was there
that, despite her best efforts, she was unable to do so
at that time?
Lydia Fraser-Ward: I mean it’s a natural reaction to have. If you are
somewhere where you’re miserable and you want to go
home, you give the answers that are required to go home.
Ms Troup: Yes.
Lydia Fraser-Ward: So why would you say, “Oh, no, I don’t feel I can keep
myself safe. Oh, no, I don’t think I can take care of
my children or myself and I am a risk to myself”.
Ms Troup: Yes.
Lydia Fraser-Ward: Because you know that you are going to be required to
stay longer. So it’s only natural –
Ms Troup: Indeed.
Lydia Fraser-Ward: – that she would have said that because she was so
horribly miserable on this ward.
Ms Troup: Yes.
Lydia Fraser-Ward: Yes.
Ms Troup: As a result of that and that she was far from home, in
fact, I think I understand that efforts had been being
made to find a bed in a mother and baby unit closer to
home and by the following day, 27 October, a bed had
become available in Chelmsford?
Lydia Fraser-Ward: That’s right. I believe it was the 27th.
Ms Troup: Yes. At that stage, though, it was decided that Pippa
was too unwell to be transferred to another mother and
baby unit because of the physical symptoms that she was
then –
Lydia Fraser-Ward: I think there – yes, sorry to interrupt.
Ms Troup: No, no.
Lydia Fraser-Ward: I think there was a concern of infection controls.
Ms Troup: Yes.
Lydia Fraser-Ward: They didn’t want to transfer her to the Chelmsford MBU
because they were concerned she would bring the virus to
that unit.
Ms Troup: I understand.
Lydia Fraser-Ward: So they were keeping her in isolation in Winchester. But what’s ironic is that they still agreed to send her home. They didn’t feel there was a necessity for her to be in isolation at home.
Ms Troup: Yes. So the decision was – it was decided that the bed at the MBU in Chelmsford would be held until Monday, 31 October?
Lydia Fraser-Ward: Yes.
Ms Troup: And just to ensure that I understand, she was to go home to Essex and then she was to return to the unit in Winchester on Saturday, 29 October only to be returned to Essex again on Monday, 31 October. That was the plan?
Lydia Fraser-Ward: This is what I gather from the report that I have seen –
Ms Troup: Yes.
Lydia Fraser-Ward: – which doesn’t make any sense to me at all.
There is basically a bed at her local MBU near her home, which she’s been trying to get into all this time. The bed is being held for her –
Ms Troup: Yes.
Lydia Fraser-Ward: – and Winchester decide that it’s in her best interests, instead of being kept in their specialist mother and baby unit, where she’s in isolation, instead to send her home. And then I see – I see notes to the effect that she was going to go back there to be
formally discharged. So she’s not been discharged.
She’s on home leave for a night –
Ms Troup: Yes.
Lydia Fraser-Ward: – as part of this plan to prepare the person. You
know, a little bit of leave, a little bit of local
leave, a little bit of home leave, then discharge.
But point is that she’s not being discharged. The
plan was to transfer her to another MBU because she
clearly needed more treatment.
Ms Troup: Yes.
Lydia Fraser-Ward: But, nonetheless, she was desperate to go home and the
ward, I am sure, probably didn’t want her around if she
was infectious.
Ms Troup: Yes.
Lydia Fraser-Ward: So they were like, “Let’s send her home for the night.
Then we’ll formally discharge her and she can go to the
Chelmsford MBU on the Monday”.
Ms Troup: Yes.
Lydia Fraser-Ward: But as – I was not aware of it, my mother was not aware
that the plan was for her to go back to Winchester and
the only reason I know that or believed that that was
the case is because I’ve seen it in her notes.
Ms Troup: I understand.
Lydia Fraser-Ward: But I don’t know if that was really ever going to be the
plan or not. I don’t know.
Ms Troup: Thank you. Lydia, I am being told that it’s 1.15 or a little bit after that and, Chair, I wonder if this might be the time for us to break for lunch.
I’m being asked that we might need a 45-minute lunch break if you are content with that.
The Chair: Fine. All right.
Ms Troup: Thank you.
(1.19 pm)
(The Lunch Break)
(2.04 pm)
The Chair: Ms Troup.
Ms Troup: Thank you, Lydia we had come to the point, we were talking about the fact a decision had been made, despite the events we have covered on the ward in the MBU in Winchester that, although Pippa’s leave would be postponed, she would nonetheless go home –
Lydia Fraser-Ward: Yes.
Ms Troup: – and we have talked about the arrangements for what you know of how that would happen, because a bed was waiting for her in Chelmsford?
Lydia Fraser-Ward: That’s right, yes.
Ms Troup: My understanding and, as far as you know, is that nobody in Chelmsford was alerted to the fact that, during the course of those days, the Friday and the Saturday, Pippa would be at home?
Lydia Fraser-Ward: As far as I know, I don’t think they were or, if they are, there is no reference to that in any of the notes.
Ms Troup: Yes. The plans in place for supporting Pippa during her home leave amounted to a telephone call?
Lydia Fraser-Ward: That’s right. So technically, because Pippa hadn’t been discharged from Winchester yet, she was still under their care.
Ms Troup: Yes.
Lydia Fraser-Ward: She was on temporary home leave, not discharged, so that meant that she sort of fell between support networks.
Ms Troup: Yes.
Lydia Fraser-Ward: She wasn’t the responsibility of the home treatment team because she was not discharged; she wasn’t under the care of the Essex team because she hadn’t yet been transferred there –
Ms Troup: Yes?
Lydia Fraser-Ward: – and she wasn’t really under the care of Winchester because they were so far away all they could do is telephone her. So she wasn’t really under anyone’s care any more.
Ms Troup: Yes.
Lydia Fraser-Ward: Not in the first person anyway.
Ms Troup: I understand. In the event, when that telephone call came, it was from a student –
Lydia Fraser-Ward: (Witness nodded)
Ms Troup: – or a student Healthcare Support Worker, this was on 28 October, and my understanding is that, in that telephone call, Pippa immediately reported that she wanted to die –
Lydia Fraser-Ward: Yes.
Ms Troup: – and that she had been thinking about going out for a walk by herself?
Lydia Fraser-Ward: That’s right. Yes, so 28 October was a Friday. I believe she had come home the day before on the Thursday, so even though she had been very poorly Wednesday night, she had stayed the night instead of coming home.
Ms Troup: Yes.
Lydia Fraser-Ward: Sent home on the Thursday and then, on the Friday morning, she received this phone call to check in on her when she said she wanted to die.
Ms Troup: Yes, as a result of that, there was a further a follow-up call later that day –
Lydia Fraser-Ward: Yes.
Ms Troup: – I think in the evening and, during that call – I’m sorry, I should go back. In the first call, Pippa having reported and having expressed a wish to die, she had essentially – she had simply been told to try to keep herself safe?
Lydia Fraser-Ward: Yes, “Try and keep yourself safe and I will call back later today, and see how you are doing”.
Ms Troup: Yes, in the later call, and we have talked about the fluctuations in Pippa’s mood, Pippa reported that she was feeling better?
Lydia Fraser-Ward: Slightly better that evening –
Ms Troup: Yes.
Lydia Fraser-Ward: – yes, that – she said she was feeling much because she had gone out for that walk but with her husband –
Ms Troup: Yes.
Lydia Fraser-Ward: – and the children, I believe, as well.
Ms Troup: Yes.
Lydia Fraser-Ward: And when she came home she had this call and said she was feeling much better but, by this point in the evening, the family was starting to become unwell because they had contracted the virus that she had caught from the mother and baby unit.
Ms Troup: Yes.
Lydia Fraser-Ward: So, as far as I’m aware, she didn’t tell the clinician on the phone that the family was starting to become unwell, either they hadn’t presented symptoms yet or she somewhere didn’t tell them.
Ms Troup: Or she just didn’t tell them, and, in any event, nobody from Winchester sought to speak to any member of Pippa’s family or support network who were there at the time, either to interrogate further what Pippa was saying about feeling slightly better –
Lydia Fraser-Ward: Yes.
Ms Troup: – or just to check in, in a more general sense?
Lydia Fraser-Ward: That’s right. As far as I am aware, they just spoke to her.
Ms Troup: That was the last contact that Pippa had, in fact, had with any healthcare professional; is that right?
Lydia Fraser-Ward: That’s right, yes.
Ms Troup: As I understand it from your witness statement and you did take us through this in your commemorative evidence, the following morning, both your mother and Pippa’s husband, having been very unwell overnight, Pippa slipped out of the house in a quiet period?
Lydia Fraser-Ward: Yes, so it was in the early hours of the morning. I am not sure exactly what time but my mother thought she was with her husband, her husband thought she was with my mother.
Ms Troup: Yes.
Lydia Fraser-Ward: They had both been vomiting through in the night and were both feeling unwell and they were just starting to fall asleep and sleep it off, having had a long night of being unwell, and, from what I was told, Pippa had very calmly cleaned the bathroom and then quietly absconded from the house.
Ms Troup: Yes.
Lydia Fraser-Ward: That was it.
Ms Troup: And she died, we know, by stepping in front of a train at the local train station?
Lydia Fraser-Ward: So the walk she had done the day before with her husband, she had asked to walk down towards the railway line and he had managed to persuade her not to walk that way because he obviously was concerned, he was like, “No, we are not going to walk that way”.
Ms Troup: Yes.
Lydia Fraser-Ward: Then, yes, the next morning, she went straight down to a level crossing near the station, near where she lived, yes.
Ms Troup: Yes, thank you.
Lydia, when we started your evidence, I talked about the fact that you have provided such a comprehensive witness statement, and you make a number of detailed recommendations for change there, as well as giving very full details about the particular concerns that have arisen in your mind, both from what you knew in relation to Pippa’s care and treatment at the time, and from the documents that you have seen thus far?
Lydia Fraser-Ward: Mm-hm.
Ms Troup: Some of the recommendations you make, we have already covered, many of them, and we have talked through those as you have explained to us what the circumstances of Pippa’s care and treatment were. Just looking at those now, if you could have a look please at page 55 of your witness statement.
One of the things that you ask this Inquiry to note is that you believe that the recommendations you are making in this witness statement are systemic issues which are likely to apply not just in Essex. Of course, a great deal of Pippa’s care was outside of the county?
Lydia Fraser-Ward: Yes. I mean, there are definitely some systemic problems without a doubt, there clearly seem to be some problems that are not limited purely just to Essex. I am not saying that Essex is without fault because clearly errors were made, mistakes were definitely made with my sister’s care by the Essex Trusts that were responsible for her care.
But, clearly, there are much wider problems. I understand the scope and the geographic limitations of this Inquiry are specific to Essex. However, it I think it’s important to highlight how these are indicators of much broader problems within NHS mental health services.
Ms Troup: Yes.
Lydia Fraser-Ward: For example, lack of beds, which I think has been stated quite a lot, clearly a lack of specialist provision, an inconsistency with continuation of care. So where a patient is placed out-of-area seems to be a lack of clarity over the responsibility for who is having oversight of that patient’s progress.
I do understand from some of the evidence provided by EPUT as part of this Inquiry that they are now putting no place a sort of care coordinator role that will oversee patients out-of-area but it does feel that that should have been introduced a long time ago.
Ms Troup: Yes.
Lydia Fraser-Ward: And I would like I would be interested to find out through this Inquiry how comprehensive that’s going to be. If it is a matter of someone updating a spreadsheet once a week to make sure that a patient is still in a certain hospital then, in my view, that is insufficient.
I believe that that role should be a person who actually is familiar with the patient, who actually has met the patient, knows their medical history and is a continued point of contact, not just an assigned medical professional that may change from week to week.
Ms Troup: Yes.
Lydia Fraser-Ward: You need that continuation of care within the service from someone.
Ms Troup: Yes.
Lydia Fraser-Ward: It needs to be just one person who sort of knows where you are –
Ms Troup: Yes.
Lydia Fraser-Ward: – especially if you are out-of-area, who can have that oversight and make sure that you are receiving the treatment that you require. I think that’s really important to stress. It’s not enough to just offer a person, any person –
Ms Troup: Yes.
Lydia Fraser-Ward: – to keep track of where a patient is. It needs to have that personalised one-to-one contact with an individual –
Ms Troup: Yes.
Lydia Fraser-Ward: – who can know what’s in the best interests of the patient, which is why the mention of an advocate earlier, I think, is so important. It was a really positive good offer from Staffordshire that clearly worked in my sister’s favour, that she felt she had someone to speak for her. And I believe that advocates – it doesn’t have to be the same person all the time but anyone that’s suffered mania or any kind of mental health condition that may affect their ability to judge what is in their best interests, should have an advocate at all times –
Ms Troup: Yes.
Lydia Fraser-Ward: – who is very familiar with their history, who can – even if they are no longer having or displaying symptoms of mania – it is hard for me to say this because I have never experienced it myself but, from this contact that I have had with a loved one, what I would urge and recommend from this Inquiry is that there is a representative for a person who has suffered that kind of illness because, even when you are well, I imagine there will be a degree of uncertainty about what exactly happened –
Ms Troup: Yes.
Lydia Fraser-Ward: – during the time when you were very unwell. And to sort of reflect on that period and know fully what happened or know fully how to – you know, how to ensure your best interests are being kept at the forefront of your treatment.
Ms Troup: Yes.
Lydia Fraser-Ward: It’s important to have an outside eye. I mean, back in the day, as we would say, our family GP would know us, we would grow up with them, they would remember what we had been through. They would be able to advise on best treatment for you because they know you.
Ms Troup: Yes.
Lydia Fraser-Ward: And I guess if there are patients who are likely to suffer – I say suffer, I don’t mean that word, I’m sorry – if there are patients that are likely to undergo or live with mental health conditions that affect their understanding of reality or that cause them to doubt their own memories, their own life experiences –
Ms Troup: Yes.
Lydia Fraser-Ward: – then that patient deserves to have a representative who can speak for – you know who can support them with making judgements about their treatment going forward.
Ms Troup: Yes.
Lydia Fraser-Ward: It is very hard for that person to be a family member or even a close friend –
Ms Troup: Of course.
Lydia Fraser-Ward: – because you are subjective. So obviously, as part of this Inquiry, many of the Core Participants, myself included, want families to be more closely involved, of course we do. We want to be involved in our loved one’s care. However, I say that in the same breath as we are also sometimes conflicted.
Ms Troup: Of course.
Lydia Fraser-Ward: We want our loved ones to come home, we want to take care of loved ones. When our loved one is begging us, “I want to come home”, how can you say, “No, you must stay, you must – I am not going to” – if someone you love is begging you for this, that or the other, all you want to do is support them and you believe that they know what they want and sometimes that can mean it’s difficult for us to make the best decisions.
Ms Troup: Of course.
Lydia Fraser-Ward: If you had a third-party advocate, which should really be their doctor, their clinician, their psychiatrist, whatever, that person’s role is to say, “All of this in mind, I still feel that you could do with further treatment, further medication, or a trip home”, whatever.
But because patients are seeing so many different doctors, so many different specialists how can you have that continuity of care with anyone within the NHS? You can’t. We don’t have the luxury of that one-to-one time.
Ms Troup: Yes.
The Chair: You also made the point, didn’t you, about the patient’s desire to protect the family, which might be overcome by somebody else advocating on their behalf?
Lydia Fraser-Ward: Absolutely. I mean, as we have discussed today, my sister was very adept at masking and many patients are.
Ms Troup: Yes.
Lydia Fraser-Ward: For whatever reasons, and you need a third party, an outside eye to say, “Look, I know this person, I’ve seen this person in highs and lows, and I think right now, although they may appear to be doing better, they really actually still need more support in this area or that area”.
Ms Troup: Yes.
Lydia Fraser-Ward: You know, it’s a luxury that we may not be able to afford within the NHS at this time but I truly believe, if there is an advocate for those most vulnerable patients that is with them, it could save lives.
Ms Troup: Yes. Thank you. That kind of continuity of care and what you are talking about really, is this fair, is an individualised approach to care which is continuous and from someone who has ongoing knowledge of that person and, as you say, of how they might present, that would also allow for a proper overarching risk assessment to be carried out, which is not entirely reliant on whatever that person is saying on a given day or at a certain point on a given day, because one of the other points that you make throughout your witness statement is that all the correspondence and all the engagement from the Trust that went to Pippa’s husband, he, of course, relied on, he relied on guidance from those clinicians –
Lydia Fraser-Ward: Yes.
Ms Troup: – and so when he was told home leave is fine and she’s coming home, that placed effectively your mother and Pippa’s husband on suicide watch –
Lydia Fraser-Ward: Basically, yes.
Ms Troup: – without guidance and –
Lydia Fraser-Ward: Sorry to jump in –
Ms Troup: No, please do.
Lydia Fraser-Ward: – that’s effectively what it was.
Ms Troup: Yes.
Lydia Fraser-Ward: They were on suicide watch with no support, information, specific to suicide at all. I think there was a small handout given about anxiety –
Ms Troup: Yes.
Lydia Fraser-Ward: – you know, but it wasn’t enough, it was insufficient. And when you are being told, “Oh, your loved one is well enough to come home”, I mean that’s a case for celebration, “Great, come home, finally, you are home, let’s be together”.
Ms Troup: Yes.
Lydia Fraser-Ward: Not, “Oh, we’re sending them home because, quite frankly, we don’t really want them on the ward right now and it would be more convenient if they weren’t here”, or, you know, “Maybe this might help but we don’t know for certain if it will help but let’s give it a try”.
Ms Troup: Yes.
Lydia Fraser-Ward: I mean, doing things like that it puts lives at risk. Pippa’s life was put at risk by sending her home. I am not saying that she wouldn’t have tried to take her life another day. It could have happened later, it might still have happened but I do know that sending her home almost guaranteed her death because it was saying, “You are now out of the hands of medical professionals” –
Ms Troup: Yes.
Lydia Fraser-Ward: – “and you are in the hands of, basically, your family and now your family has been made incapacitated, so they can’t look after you either” –
Ms Troup: Yes.
Lydia Fraser-Ward: – “so you have no support”. And I do not understand, I will never understand, how a patient who was as high risk as my sister being sent home knowing everything that they knew, knowing that she had made multiple attempts on her life, just within a few days, you know, and immediately before leaving, if she is saying to you, “I want to die”, in no uncertain terms not, not half – not equivocating, saying directly, “I want to die”, that the appropriate medical response to that is to call back later, I will never understand that.
What more does a patient have to do to inform medical professionals that they need help.
Ms Troup: Yes.
Lydia Fraser-Ward: There is nothing more that she could have said or done to alert medical professionals that she needed help and to not even sort of arrange for a home treatment team person to come and visit – for no one to come and visit to just sort of, “Let’s wait it out” …
Ms Troup: Yes. But when also, as you have pointed out, there was a bed waiting for her there in Chelmsford?
Lydia Fraser-Ward: There was, yes. I will never understand why no action was taken, or that – what I think upsets me most, actually, within all of this, apart from my sister’s actual death, is that in the inquest, when the report is being made by Southern Health into what happened, they still feel that she received appropriate care and that they wouldn’t change anything that was done.
Ms Troup: Yes.
Lydia Fraser-Ward: How can that be the case? How? She died. That is the ultimate worst outcome; how can it be appropriate care? And to – what frightens me about that is that further patients will be put at risk because they seem to think that that is appropriate, to send patients home when they are suicidal, to provide little to no information or support for families –
Ms Troup: Yes.
Lydia Fraser-Ward: – and to assume that, even if someone is reporting suicidal thoughts, it is still not enough to hospitalise them again.
Ms Troup: Yes.
Lydia Fraser-Ward: I don’t know what more Pippa could have done to ask for help –
Ms Troup: Yes.
Lydia Fraser-Ward: – or how she couldn’t have made it any clearer, and the fact that the Trusts that were responsible for her care not only failed to acknowledge that they didn’t do enough, but that they didn’t even – EPUT didn’t, as far as I am aware, provide any information or evidence for her inquest.
Ms Troup: No.
Lydia Fraser-Ward: That we don’t – still to this day, don’t have any information about her stays in EPUT facilities.
Ms Troup: Yes.
Lydia Fraser-Ward: I don’t understand what’s the point of an inquest if trusts are not required to provide information about what happened. How can any lessons be learned? They’re constantly talking about learning lessons but how can you be learning lessons if you are not providing information and not attending, not listening, not following up with families?
Ms Troup: Yes.
Lydia Fraser-Ward: You know, the whole point about inquests, surely, is to make sure this never happens again and yet it does. We keep seeing more patients. How many patients? We still don’t even know in this Inquiry how many patients, how many people have died, not just been ill but have actually lost their lives.
Ms Troup: Yes.
Lydia Fraser-Ward: We don’t know because there are so many.
And for my sister to sort of become a statistic, a number, a bit of data that can’t be found, can’t be traced, can’t be logged: she is not a number, she’s not a statistic. She was a person that people loved and cared for.
Ms Troup: Yes.
Lydia Fraser-Ward: And, surely, we should be treating these patients how we would wish to be treated if we were to become ill?
Ms Troup: Yes.
Lydia Fraser-Ward: Because what happened to Pippa could happen to any woman, and it shouldn’t have happened, what happened to her.
Ms Troup: Lydia, thank you.
Lydia Fraser-Ward: That’s okay.
Ms Troup: At this stage, unless there is anything else in your recommendations or any other part of your witness statement that you particularly want to highlight now, what I was going to say is that I don’t have any questions for you and that, unless the Chair has any questions for you, that that would conclude your evidence, and I understand we did see some photographs of Pippa when you gave your commemorative evidence in September, but I understand that there is another photograph today that, in a moment, unless there is anything else that you want to add, I’ll ask to go up on the screen.
Lydia Fraser-Ward: I would just like to finish by saying I know that there never seem to be enough resources within the NHS and to request certain provisions feels like a luxury but, if anything comes out of this, I ask that we ask for a more person-centric approach to care.
Ms Troup: Yes.
Lydia Fraser-Ward: Everything seems to be about systems and processes and procedures, and yet so often we see these procedures and protocols not working or failing patients because they are not being treated necessarily as individuals and, if we want people to get better, if we want for ourselves and our loved ones and our children to get better, to make good recoveries, lifelong recoveries, because many of these patients will have lifelong illnesses that they have to live with –
Ms Troup: Yes.
Lydia Fraser-Ward: – and that their families have to live with, that the treatment needs to be centred on the individual, that there is no one-size-fits-all approach to mental health care and that you can’t just put a sort of date on being well on persons. Just like you wouldn’t with any physical illness. You wouldn’t say to a cancer patient, “You are going to be well by this date”, you know, or someone who has broken this leg, “You are going to be fine and up and around about this exact point”.
Ms Troup: Yes.
Lydia Fraser-Ward: So to give room to breathe for persons to be given time to recover and to constantly find ways to personalise that care, have a continuation of care and, where that isn’t possible, where treatment does need to be given out-of-area or with different members of staff, that there is some sort of resource, some sort of provision to ensure that there is this overarching – as you say, overarching view on how is this person doing –
Ms Troup: Yes.
Lydia Fraser-Ward: – that there is some sort of safety net in place.
And I would say the same for families involved in inquests, too. It feels like the inquest happens and it’s done, “Bye, we have heard you. The lessons will be learnt, goodbye”. And, actually, the real world doesn’t work like that. We are not all bits of paper being pushed around on bits of table. You know, why is there not a facility within inquests to be staying in touch with families afterwards, so that families know these lessons are being learned. Let’s see what’s happening because families don’t stop caring one day when the inquest is over.
Ms Troup: No.
Lydia Fraser-Ward: I want to know that the things that you said were going to change have changed.
Ms Troup: Yes.
Lydia Fraser-Ward: I want contact, I want to know that things aren’t – mistakes aren’t going to be repeated and I want you to talk to me and ask me what I think –
Ms Troup: Yes.
Lydia Fraser-Ward: – whether you want to hear it.
But, you know, this is about a relation – it is about relationships, isn’t it? It is about staying in touch and talking to people, not just talking with families whilst your loved one is in the hospital but beyond.
Ms Troup: Yes.
Lydia Fraser-Ward: About understanding that you have to keep talking, you have to keep checking in, you have to keep learning from what’s happened, so that it hasn’t all been in vain.
That’s all really.
Ms Troup: Thank you.
The Chair: Thank you very much indeed. We are going to see the photograph of your sister but, before we do, I want to say thank you very much indeed for your incredibly powerful evidence.
Lydia Fraser-Ward: Thank you.
The Chair: We really appreciate it, thank you.
We have another witness so I will rise.
Ms Troup: We do. A short break, yes.
The Chair: 10 minutes?
Ms Troup: Five to ten minutes.
The Chair: Five to ten minutes.
(2.31 pm)
(A short break)
(2.43 pm)
The Chair: Ms Pucks.
Ms Pucks: Good afternoon, Chair. We are ready for the
evidence of Alan Oxton. Please can he be sworn, thank
you.
Alan Oxton
ALAN OXTON (affirmed).
Questioned by Ms Pucks
Ms Pucks: Could you please state your full name for the
record?
Alan Oxton: Yes, Alan James Oxton.
Ms Pucks: Thank you. You are the son of Stephen Alan Oxton; is
that right?
Alan Oxton: Yes, yes, I am.
Ms Pucks: Your father was born on 1 November 1958?
Alan Oxton: Yes.
Ms Pucks: He died on 1 April 2012?
Alan Oxton: Yes.
Ms Pucks: By way of background, the Inquiry sent you what we term
a Rule 9 request, requesting your evidence for the
Inquiry; is that correct?
Alan Oxton: Yes, it did.
Ms Pucks: In response to that request, did you provide a witness
statement?
Alan Oxton: I did, indeed.
Ms Pucks: Is it right that you have a copy in front of you?
Alan Oxton: Yes, I do.
Ms Pucks: At the top of your copy, it says Alan Oxton, your name?
Alan Oxton: Yes.
Ms Pucks: Is it right that, on the last page, it gives your –
well, it’s not exactly a signature but it’s your name as
a signature?
Alan Oxton: Yes.
Ms Pucks: It is dated 24 May 2025?
Alan Oxton: Yes.
Ms Pucks: Have you had the opportunity to review that recently?
Alan Oxton: Yes, I have.
Ms Pucks: Can you confirm that it is accurate?
Alan Oxton: I can confirm.
Ms Pucks: Is it right that you would like this statement to be
considered as your evidence to the Inquiry?
Alan Oxton: Yes, please.
Ms Pucks: Thank you. Now, I will be asking you some questions
about your witness statement, we will not be going
through it line by line. But you can be assured that
the Chair and the Inquiry team will consider all of it
in detail and very carefully.
I would also like to acknowledge that you have
provided commemorative evidence to the Inquiry before
and we are very grateful to you for your assistance,
thank you.
Alan Oxton: Thank you.
Ms Pucks: Now, just as a reminder, I will not be asking you to
name any staff –
Alan Oxton: Okay.
Ms Pucks: – members. That is in line with the restriction order
that has been imposed.
Alan Oxton: Yes.
Ms Pucks: The evidence that we will cover today will be structured
in three parts: first, I will go through a timeline in
relation to your father’s care; second, I will ask you
some questions about your concerns in relation to his
care, his treatment, his death and also what happened
after his death; and third and finally, I will ask you
some questions about your recommendations to the Chair.
Alan Oxton: (Witness nodded)
Ms Pucks: Is that all right?
Alan Oxton: Yes, thank you.
Ms Pucks: Thank you. If I can start therefore with the timeline. Now, this is in paragraphs 2 to 17 of the witness statement –
Alan Oxton: Mm-hm.
Ms Pucks: – in case that assists. Now, is it right that your father’s mental health difficulties began following the murder of his own father in January 1998?
Alan Oxton: Yes. My – his dad, my grandad was murdered in – stabbed in London in 1998 and my dad was working as a lorry driver and he lived – he was overseas in Germany, so he got flown back from work following his death and then went through all the subsequent investigation with the police and identifying the body, et cetera.
Ms Pucks: Following the incident, is it right that he started to suffer from flashbacks of that process?
Alan Oxton: Yes. From memory, what he used to go on about was he used to – identifying the body was the main – and he had a lot of anger about his father’s killer and him being released from prison. Yes.
Ms Pucks: Am I right in understanding that he first sought assistance from his GP some two years after the incident?
Alan Oxton: Yes.
Ms Pucks: Was this initial – well, in fact having sought
assistance from his GP, was there a referral?
Alan Oxton: Yes, it wasn’t accepted the first time round and it took
subsequent referrals from his GP for them to actually
admit him into the mental health and give him treatment.
Ms Pucks: Is it right that he first sought assistance on
26 January but it wasn’t until 14 February and the
re-referral that, in fact, an assessment by a community
psychiatric nurse took place?
Alan Oxton: Yes, that’s exactly right.
Ms Pucks: Is it right that he was then diagnosed with
post-traumatic stress disorder?
Alan Oxton: Yes, directly back to his father’s murder.
Ms Pucks: Yes. He accepted cognitive behavioural therapy and four
sessions of eye movement desensitisation?
Alan Oxton: Yes.
Ms Pucks: I think your statement says “restricting” but you think
that this should be reprocessing or restructuring, in
relation to the treatment that he received?
Alan Oxton: Yes, he sought treatment up until – with the same lady,
the same nurse up until about 2009.
Ms Pucks: That’s right.
Alan Oxton: That’s when he was discharged.
Ms Pucks: It was in October 2009 that he was discharged; is that
right?
Alan Oxton: Yes.
Ms Pucks: During this time period, did you say that he continued to receive treatment from the same nurse?
Alan Oxton: Yes, the majority of it was from the same lady.
Ms Pucks: Thank you. Following his discharge in October 2009, is it right that his mental health then deteriorated again?
Alan Oxton: Yes. He would be very up and down but then in 2009, he got – or, sorry, he then got re-referred again by his GP.
Ms Pucks: Yes. In fact, on 5 February, so some four months after his discharge; is that right?
Alan Oxton: Yes, it didn’t take too long.
Ms Pucks: He received top-up support but was discharged again in May 2010; is that right?
Alan Oxton: Yes.
Ms Pucks: Then is it right that he was re-referred on two occasions thereafter by his GP but these were refused?
Alan Oxton: Yes. He saw – he received support from a lady who was she was in charge of Support After Murder and Manslaughter and they offered quite a bit of support. He went on retreats with them. And, obviously, they have got experience with help supporting families who have had loved ones murdered, and they were his main support because of the Trust wouldn’t – didn’t readmit him.
Ms Pucks: Is it right that on 19 February 2011, so the following year, your father attempted an overdose?
Alan Oxton: Yes, that was the first one. I believe it was at Colchester General Hospital.
Ms Pucks: Yes.
Alan Oxton: But, again, I haven’t got full access to the medical records, but I recall the first one being at Colchester.
Ms Pucks: Is it right that he was assessed again four days later, following contact by Rethink and, following that reassessment, there was a referral to a consultant psychiatrist?
Alan Oxton: Yes.
Ms Pucks: Is it right that that consultant psychiatrist advised that an outpatient appointment was not appropriate?
Alan Oxton: Yes, you would imagine and you would like to think that, once someone tries to actively take their life for the first time, that they would be – that they would be readmitted and there would be some form of care and support there for them, but I don’t know the background behind it or the sort of like reasoning behind it. But you would like to think that there would be some form of support after that, but there wasn’t.
Ms Pucks: Is it right that, after that refusal, as it were, your father raised his concerns with the Trust about the services he received?
Alan Oxton: Yes.
Ms Pucks: Do you know if there was any outcome to his doing so?
Alan Oxton: I believe he met with the Community Mental Health Team manager in Colchester to discuss his concerns but that was all I’ve – all I’ve got from the records.
Ms Pucks: Thank you. Is it right that on 27 April, so some two months later, your father overdosed on medication and alcohol and this time was taken to Broomfield A&E?
Alan Oxton: Yes, that was correct and this one was – it was much more serious in terms of him, he was unconscious, yes, whereas I think the first one was more of a – felt like more of a “I need help”. The second one, it was – it was him trying to end his life and meaning it.
Ms Pucks: Is it right that he was then, in fact, taken to the Linden Centre under Section 2?
Alan Oxton: Yes, he was sectioned there for – from 28 April to 5 May.
Ms Pucks: Following his discharge, did both yourself and your father make written complaints about his lack of care and treatment?
Alan Oxton: Yes, we did, because we didn’t feel like it was properly addressed after the first one, and we felt like we weren’t getting anywhere. I believe I also wrote to the local MP. Yes.
Ms Pucks: Thank you. I will ask you some questions about those complaints when we get to your concerns. In May 2011,
your father attended a psychological assessment and
specialist psychometric testing which concluded that he
was still suffering from complex trauma with elements of
PTSD and personality difficulties; is that right?
Alan Oxton: Yes, that’s correct.
Ms Pucks: His CPA review in July concluded that he should continue
with outpatient clinic appointments with his CPN; is
that right?
Alan Oxton: Yes, that is.
Ms Pucks: Was he then also added to the waiting list for PTSD
therapy?
Alan Oxton: Yes, and, to my knowledge, he should have been added to
the list far sooner and the issues addressed. But for
some reason the Trust refused, didn’t want to help –
just didn’t help.
Ms Pucks: On 21 October your father began cognitive behavioural
therapy; is that right?
Alan Oxton: Yes.
Ms Pucks: Yes, and shortly thereafter, four days later, he
overdosed for a third time?
Alan Oxton: Yes. He was in – he attended an inquest in regards to
his father’s death. Yes.
Ms Pucks: Was he admitted following this overdose?
Alan Oxton: Admitted? He wasn’t admitted, no.
Ms Pucks: He wasn’t admitted?
Alan Oxton: No.
Ms Pucks: Yes, in fact, is it right that he was again referred to the care of the community psychiatric nurse?
Alan Oxton: Yes.
Ms Pucks: Thank you. Now between November 2011 and March 2012, is it right that he attended multiple outpatient appointments with his consultant and the CPN?
Alan Oxton: Yes.
Ms Pucks: Then on 7 March, he took a fourth overdose and was referred to the Crisis Resolution and Home Treatment team?
Alan Oxton: Yes, for the fourth time, yes.
Ms Pucks: He was – yes, he was assessed on 8 March and discharged to the team for seven days thereafter; is that right?
Alan Oxton: Yes. The individual then – who assessed him in the hospital then came to the home address and saw him a number of days later.
Ms Pucks: Now, that provides the background to the 31 March and 1 April, which is the time period when your father passed away.
Alan Oxton: Yes.
Ms Pucks: Now, is it right that on 31 March your father called the Crisis Resolution and Home Treatment team and requested to be sectioned?
Alan Oxton: Yes. Before that though, he phoned me. I – at the time I lived in Manchester and worked up there. I was just finishing a night shift, so I put my phone onto silent and my – so I didn’t hear the call but I had a voicemail from my dad in a distressed situation, wanting to end his life, he had had enough and he wasn’t happy, and he was in severe distress.
So I awoke – received the phone call from – or I didn’t receive the phone call. I got woken up by my partner at the time because my dad’s girlfriend had phoned her to let her know that what had happened and he had phoned the Crisis Resolution and Home Treatment team, requested to be sectioned. Then his house backed onto a – the main railway tracks between – to Liverpool street from, like, Colchester. He lived at Witham at the time, and he had gone out, it was all big hedges, so his arms were all cut because all the thistles, but he managed to fight his way through it and get onto the railway tracks, which is when the police got him and sectioned him.
So I missed his call and that was the last time he sort of made contact with me, was me finding out that – me finding a voicemail which kind of lives with me, really.
Ms Pucks: You said, the police sectioned him?
Alan Oxton: Yes, they got him and they took him to Shannon House in Harlow.
Ms Pucks: That’s right. We will go through the details of the transfer but is it right that he was then transferred to The Lakes in Colchester?
Alan Oxton: Yes. I – they, they done the initial assessment in Shannon House. Then they took him to – they transferred him later on to The Lakes in Colchester. I believe from notes I have received and records I have got that they were going to take him to the Linden Centre but they couldn’t because the section that they would have took him to, I don’t know, the ward that had been needed treatment because the police had used CS gas in it, or something like that, so they couldn’t take him to where he had previously been and who knew about him.
Ms Pucks: Do you know if you or your family were involved in the discussions about where he would go?
Alan Oxton: No. I was just told that he was taken to Shannon House.
Ms Pucks: He arrived at The Lakes on 31 March.
Alan Oxton: Yes.
Ms Pucks: Is it right that several hours – well, in fact, the morning after his arrival at The Lakes, your father barricaded himself into his room and died by ligature?
Alan Oxton: Yes, in the morning after. So he spent the night there and when he wasn’t being watched, observed, which is another issue which I am sure we will come onto in a little bit, he barricaded himself into – in his room and still had access to his belt, which is another point of which I have issues and concerns that I would like to raise over, and he used his belt as a ligature – for ligature on the window of his ward.
Ms Pucks: Thank you. I would like to turn to your concerns now, if I may.
Alan Oxton: Mm-hm.
Ms Pucks: The first concern relates to your father’s treatment in the community. Now, you referred to the fact that your father was refused a referral on several occasions.
Alan Oxton: Yes.
Ms Pucks: In fact, I have four: 26 January 2000; 8 July 2010; 28 July 2010 and February 2011, after his first overdose.
Alan Oxton: Mm-hm.
Ms Pucks: On any of the occasions where the referral was not accepted, were you or your father provided with any reasons why?
Alan Oxton: I wasn’t. I am not entirely sure my father was ever provided any. Very hard to say because he wrote a number of complaints, raised it a number of times, so did his GP, so I cannot recall I’m afraid. But …
Ms Pucks: Thank you. Is it your view that your father should have been seen sooner as an outpatient?
Alan Oxton: I believe they saw him as an outpatient too late and readmitted him too late into their care and he was already on a steep decline when he started taking – trying to take his own life on those four occasions, and I am not saying that he would be here today, I am not saying he would have been – he would have recovered and everything would have been merry. But his life would have been prolonged if they readmitted him earlier and saw him earlier before he started going on these suicidal attempts and sharp declines.
The Chair: Can I just ask you about this decline? Was he noticeably declining, each time getting worse, or was it a fairly steady presentation during the time that he was making these suicide attempts?
Alan Oxton: He – the first one, I believe was – didn’t feel as – it was more of a cry for help, I felt.
The Chair: Yes.
Alan Oxton: But the three after that, I firmly believe that they were attempts on his life and he wanted to take his own life.
The Chair: Yes.
Alan Oxton: We – my dad’s girlfriend at the time, I recall, going through a lot of his stuff after his death and she moved out of the house that they lived in together to another house, and we – I helped her move – I am not in contact with her anymore, so she couldn’t partake in …
The Chair: Yes.
Alan Oxton: But we were emptying her food cupboard to move house and, right at the back of the food cupboard, the top shelf – he was a very tall man, she was very short – right at the back, on the top shelf, was a rope with a ligature around it. So it was – it was fairly obvious what – he was going to do it one way or another.
But, yes. It was after the first one, it was …
I – my – the person who killed my granddad, his dad, he passed away in hospital – in prison, he had a heart attack in prison, and I believe that kind of coincided with when he declined.
The Chair: Right.
Alan Oxton: And part of me is of the belief that he spent such a long time trying to keep his father’s killer in prison and, after he died in prison, there wasn’t much to live for, for him, and I feel like his purpose kind of … and that’s when the steep decline started, I believe.
The Chair: Thank you, thank you.
Sorry, Ms Pucks.
Ms Pucks: Thank you. Was there anything else that you wanted to share in relation to your father’s treatment in the community?
Alan Oxton: I am sure we will go on to it later on but I took a private case against the Trust after my father’s death and the solicitors that I used had got an assessment from a – another doctor and they were of the opinion that my father’s care was below the acceptable level.
So, yes.
Ms Pucks: Thank you. If I could turn now to his admission in Shannon House first. Is it right – well, we have gone through it – it is right, isn’t it, that your father was admitted because he requested to be sectioned?
Alan Oxton: Yes.
Ms Pucks: Just to be just to be clear, why do you think it was that he requested to be sectioned?
Alan Oxton: Because he wanted to take – he wanted to kill himself. Pure and simple. His words, “If I was a dog, they would put me down”. That’s how he felt about himself. He was sick, he was unwell, and they don’t let dogs live on like that and that if he was a dog that the vets would put him down because he was unwell.
Ms Pucks: You have raised a number of concerns in your statement about father’s care at Shannon House?
Alan Oxton: Yes.
Ms Pucks: One of those concerns is that there were conflicting versions of events about what happened in relation the search of your father’s property?
Alan Oxton: Yes.
Ms Pucks: Can you tell us a little bit more about that? If it assists, it is at paragraph 18 of your statement.
Alan Oxton: Thank you. Yes. My dad was taken to Shannon House by the police, and then, when he was searched, they recorded a number of items and I believe it was only valuables that they recorded. There was conflicting accounts from two Trust employees regarding the search of my father. One stated that he was searched, a belt was taken, but I believe he couldn’t recall the colour, style or anything about the belt.
And then the witness, or the other person who was present to obviously witness these things have to be done in – to corroborate the story, the other one couldn’t remember seeing a belt, him being searched, so there was conflicting views from the NHS staff who admitted him into Shannon House. There was another one who had spent a large portion of time, I can’t remember the exact amount, I think about a couple of hours, observing my dad and he couldn’t remember seeing a belt either.
So it concerns me that you have got – someone is lying, at the end of the day, because you have got staff A saying, “We searched him, we took the belt, but I can’t recall it”; you have got staff B saying, “I don’t even recall searching him, let alone there being a belt”. Yes, it’s a lie.
Ms Pucks: Is the case, essentially, that you do not know –
Alan Oxton: No.
Ms Pucks: – what has happened in relation to his belt at Shannon House?
Alan Oxton: No, I went through – I have been through all the various investigations, inquiries, which I have been offered part of, and I have never got an answer. Never known or even got close to anyone answering the question what actually happened.
Ms Pucks: How do those inconsistencies and this lack of, ultimately, knowing what happened, how does that make you feel?
Alan Oxton: It can’t – you can’t move on without knowing, and that’s why I am here today. Because hopefully, at some point, I’ll get the answer of, “Yes, we took belt and gave it back to him”, or, “No, we didn’t take the belt”.
Ms Pucks: Still at Shannon House. You make an observation in your witness statement about concerns to do with the manner in which your father’s level 3 observations were conducted. Would you be able to tell us a bit more about that, please?
Alan Oxton: Yes, that was –
Ms Pucks: That’s at paragraph 19, if that assists.
Alan Oxton: Thank you. Yes, so he took – he was subject to level 3 observations, which, I’m no expert, but that was constant supervision, is what I was informed, and this was taking place behind a glass panel within an office, which was contrary to the inpatient observation and engagement policy because, essentially, they couldn’t – they weren’t engaging with him, they were just literally watching him. So there was no, it was hard to do a risk assessment, it’s hard to see if someone is improving, declining, all these sorts of things that they should be doing, obviously they can’t. You can’t speak to someone through a glass.
Ms Pucks: I would like to move now to the transfer from Shannon House to The Lakes. Is it right that the – well, in fact, can you remember the reason for the transfer?
Alan Oxton: Yes. From my – obviously they couldn’t take him to the Linden Centre, initially, like I said, and Shannon House only had access to a limited portion of my dad’s medical records. So they were going to transfer him to The Lakes Ward in Colchester.
Ms Pucks: So, as far as you were aware, it was not about beds or –
Alan Oxton: No.
Ms Pucks: – capacity. It was about where the information in relation to your father’s care was held?
Alan Oxton: Yes.
Ms Pucks: Thank you. Is it right that you also raised a concern about the lack of accompaniment in the transfer?
Alan Oxton: Yes. The Approved Mental Health Professional chose not to escort my dad to The Lakes from Shannon House and that they delegated the responsibility to the ambulance staff, who were transferring him.
The Approved Mental Health Professional stated that they didn’t because they had to attend another assessment. But then the serious investigation report actually identified that this wasn’t the case, they didn’t have to attend another assessment.
Ms Pucks: Right.
Alan Oxton: So they, again, in fact, lied and so, why they couldn’t transfer it why they couldn’t attend to transfer my dad is a mystery. Again, that’s something I don’t know and would like the answers to, please.
Ms Pucks: Is it right that, also by virtue of not having accompaniment from Shannon House to The Lakes, you also do not know what happened to your father’s possessions?
Alan Oxton: No. From – obviously we don’t know whether the belt was taken or whether – so whether that was given back to him, whether that was given to the ambulance staff.
The only things what were included on the property sheet what were given back to him were his mobile phone and his wallet, and then we don’t know what happened with that when he got to The Lakes because there was no – the transfer wasn’t – was done through the ambulance staff.
Ms Pucks: Yes. So, in fact, he was returned some possessions?
Alan Oxton: Yes.
Ms Pucks: But you don’t know the extent of it?
Alan Oxton: No, because they only recorded the valuables, so what else they took, I do not know. But I know that they returned his wallet and his phone because that was recorded on the property sheet in Shannon House, and then that was handed in to The Lakes Ward some time during the night.
Ms Pucks: Yes.
Alan Oxton: So that would have been returned back to him. But that to me then alarms – he can’t have been searched when he was going into The Lakes because you would have thought that they would have taken those valuables off him, like the search at Shannon House, which has its own issues regarding the belt.
Ms Pucks: Yes. I would like to move on to his arrival at The Lakes and, if I may, although I understand of course that the retention of the belt is a very key concern of yours, I would like to start by asking you about three other concerns that you raise.
Alan Oxton: Yes.
Ms Pucks: Is it right that one of your concerns is that you have no real understanding of the handover to the staff at The Lakes?
Alan Oxton: No, no idea what so happened – what happened.
Ms Pucks: Is a second concern of yours that your father was in fact, on arrival at The Lakes at around 6.30 pm, not seen until 10.00 pm that evening –
Alan Oxton: Yes.
Ms Pucks: – for the purpose of an assessment?
Alan Oxton: He arrived at 6.00 by ambulance. The doctor who was due to see him was finishing, off-duty at 9.00, at 2100 hours, so that was three hours, and then he or she transferred – notified another doctor, who was starting their shift, that they had to see my father, and then they didn’t turn up until – sorry, I don’t –
Ms Pucks: I believe your statement says 10.00 pm?
Alan Oxton: Then 10.00 pm, yes, so one hour after that shift started. I believe that there was no urgency expressed that first job is to see this man because he has been here since 6.00. Yes.
Ms Pucks: It may be a question with an obvious answer but what is your concern about this delay?
Alan Oxton: Well, my concerns are that there’s no risk assessment. He’s not been looked – he’s received no – no real form of treatment. He’s just been left and admitted into The Lakes, and that’s where he’s – and they have just kind of dumped him there, basically, it felt like to me, without any form of assessment. And I lived in Manchester and was not communicated any form – I phoned up The Lakes when I could get through to them, and they said – their words were, “He is in a place of safety, don’t worry”, which if I knew everything now what I knew then, I wouldn’t believe because there was no way that man was in a place of safety.
Ms Pucks: Is it right that, on arrival at The Lakes, he was downgraded from a level 3 observation to a Level 2 observation?
Alan Oxton: Yes. He was down – he was level 3 so, as far as, again, I am no medical expert, but he was constant level 3 while he was in The Lakes. Then when he arrived at The Lakes he was downgraded to level 2. And can I just draw my – your attention to something in this Serious Incident Report.
The Chair: Do.
Alan Oxton: In a bit on page 21, it refers to a doctor initially indicating a need for level 3 observations but then they ultimately agreed on level 2 were appropriate. So there were discussions when my father arrived at The Lakes that he should have been continued at level 3 but, for some reason, this doctor ultimately agreed with another one that level 2.
So I would just like you to highlight that.
The Chair: Was that done before he was assessed?
Alan Oxton: Yes. My father when he – when the doctor finally visited him at 10.00, he didn’t want to engage with the assessment doctor because he had been there for four – well however – between the times we stated and that he – his words were that he was tired, he wanted sleep.
The Chair: Yes.
Alan Oxton: So they have missed a key time, a large amount of time there, to assess him.
The Chair: Within that time period, having not assessed him to begin with, they downgraded his risk?
Alan Oxton: Yes, they have.
The Chair: Do you know based on what information they did that?
Alan Oxton: No, I wasn’t informed why they downgraded it. But I recall that there being a discussion, “Shall we do level 3, shall we do level 2”, and The Lakes ultimately decided on level 2. That was a question I put to the incident – Serious Incident Report, but I am sure we will go into the incident report later but, yes, thank you.
The Chair: Moving on to the belt and the search process at The Lakes. Now, you have already set out that you essentially don’t know what happened to the belt at Shannon House in the transfer to The Lakes?
Alan Oxton: Yes.
The Chair: Do you know what searches were undertaken when he arrived at The Lakes?
Alan Oxton: No, no idea whatsoever.
The Chair: Now, your statement at paragraph 22 says that staff indicated that his property was searched but nothing was removed from his person. In what context did the staff indicate this; do you remember?
Alan Oxton: No. I don’t.
The Chair: So is the position – apologies.
Alan Oxton: I don’t – at the end of the day, the wallet and the phone were handed in at a later date so, if the person was searched, surely that would have been taken off at the time of search. So –
The Chair: Yes?
Alan Oxton: – it’s a question for me that was he actually searched because he’s gone in with his wallet and his phone, which was previously taken off him.
The Chair: Yes. So, essentially, is the position that you do not know if he was searched?
Alan Oxton: No.
The Chair: You do not know, if he was searched, what was taken from him?
Alan Oxton: No.
The Chair: All you know is that he ended up in possession of the belt?
Alan Oxton: Yes.
The Chair: I want to briefly talk about risk assessments. Now, I understand that the inquest stated that the risk of self-harm was correctly assessed. But that there was an incomplete transfer of the risk assessment, is the conclusion that the inquest came to –
Alan Oxton: Yes.
The Chair: – which resulted in a lower level of observation being applied. Now I also understand from your statement that staff at The Lakes made a point to you about how your father’s previous attempts of suicide were by way of overdose and, as such, they were not concerned about forms of suicide, such as by ligature and, as I understand it, the staff also mentioned to your father’s girlfriend, when she attended the ward later after his death, that had he not had the belt he would have found an alternative method?
Alan Oxton: Yes.
The Chair: Now, what, if any, concern do you have about the way in which the staff appeared to approach your father’s risk of self-harm?
Alan Oxton: My view is that if a man or woman is going to – wants to end their life, wants to take their own life, that they will use any means necessary, and they were confident that he wasn’t a risk through ligature because previous attempts had been medication, trying to get on the train tracks and also he had expressed a desire to crash his car, killing himself.
So there’s issues and things to be raised there that, if they think that’s the situation, if they believe that they are just going, “He’s never expressed that desire before”, so –
The Chair: There is no risk of it?
Alan Oxton: – there is no risk, I believe that’s wrong.
The Chair: You have said both in evidence today and also in your statement that the staff repeatedly reassured you that he was in a place of safety, was that by way of a phone call to you, when you called them in fact –
Alan Oxton: Yes.
The Chair: – on that day?
Alan Oxton: I spoke to The Lakes the night my dad – the night of – he got taken there, so somewhere between 6.00 and 10.00 and I was told that he was in a place of safety, “Rest assured, he will be fine, we will look after him”. But that’s not the case, is it?
The Chair: No. I would like to turn to the ward environment, if I may, and there are two points that I want to ask you about that come from your statement. The first is you mentioned that your father was able to move furniture around?
Alan Oxton: Yes.
The Chair: Again, this might seem like a question with an obvious answer, but what is your concern about that?
Alan Oxton: (a) You can move it around to a state that you can barricade yourself in the room; (b) he managed to move it around undetected, considering he is on level 2 observations you would imagine that that would be pretty hard, but apparently level 2 observations mean you can throw wardrobes and a chest of drawers in front of doors and no one – no one – no one bats an eyelid.
The Chair: Thank you.
Alan Oxton: And I am sure we have gone through so many – there is so many families here and giving evidence this week giving evidence in the future, and I would be amazed if there’s not more issues where there’s barricaded rooms because, considering the Linden Centre was being treated for – because of CS gas, I am sure there was a few wardrobes and things thrown around in there and I am sure other cases have got similar nature, and I am sure there’s repeats again and again. And, yes, you shouldn’t be able to move round a wardrobe and chest of drawers while you are under observation and not – and
it not be identified or noted.
The Chair: You also refer to the window and you query whether that
had previously been highlighted to the Trust –
Alan Oxton: Yes.
The Chair: – as a cause for concern. Is this something that you
have been able to raise with the Trust?
Alan Oxton: I remember liaising with someone in the Trust and they
offered me the chance to go to look at the window.
I declined. They then stated that the window had been
changed after his death and I was shown a picture after
his death of the window being changed?
The Chair: Sorry, just to be clear, so they offered that you go and
see the window –
Alan Oxton: Which my dad hanged himself from, yes.
The Chair: Right, and then they offered to show you – well, they
sent you a picture of the change that they had made to
the window –
Alan Oxton: Yes.
The Chair: – is that right?
Alan Oxton: And, yes.
The Chair: At the time that they offered you the
opportunity to see the window, that was after or before
they had changed the window?
Alan Oxton: Both I believe.
The Chair: Right.
Ms Pucks: Do you remember what the intention was before?
Alan Oxton: No. I don’t.
Ms Pucks: Thank you. I would like to now move on to the complaints that both you and your father made about his lack of treatment. First, your father’s complaint: without giving any names, do you recall who he complained to or where his complaint was sent to?
Alan Oxton: He was – he sent it to the clinical manager of Oyster Court, the Community Mental Health Team in Colchester. So those – they would have received the referrals for him to be reassessed –
Ms Pucks: Right.
Alan Oxton: – and then they said no. Yes, those were who he referred them to.
Ms Pucks: Do you recall what effect, if any, those responses had on him?
Alan Oxton: Yes. He just felt like he was getting knocked back and each time it was getting profoundly worse, he was getting nowhere. They weren’t interested in helping him, they didn’t want to help him even though they had – it seemed to me like they had seen him as an outpatient for so long, an initial – what was it, 2000 to 2009, and there was an unwillingness to do any more until he seriously started to try and take his own life.
Ms Pucks: Did you make any complaints prior to your father’s
death?
Alan Oxton: I had, yes.
Ms Pucks: Who did you make them to?
Alan Oxton: I made them to the same.
Ms Pucks: The same place?
Alan Oxton: Yes.
Ms Pucks: Did you receive any responses?
Alan Oxton: I did and I believe that is where we had the CPA –
Ms Pucks: Review.
Alan Oxton: – the review. I am trying to think where we are now,
probably backwards.
Ms Pucks: I am about to take you to, I believe, paragraph 27 but
let’s see where we go. Did you make one complaint prior
to his death?
Alan Oxton: Is this prior to his death?
Ms Pucks: Yes.
Alan Oxton: Yes, I believe I made one.
Ms Pucks: One compliant?
Alan Oxton: Yes.
Ms Pucks: Is it right that you state that the Trust only really
engaged with you after his death, once you put in
a complaint?
Alan Oxton: Yes, it was very difficult because I wanted answers from
the Trust and The Lakes. I would come up speaking to individuals, who were the Ward Manager there, and I requested medical records, I wanted to know what had happened, ie what are the circumstances, and they didn’t – they didn’t come forward with much.
They come forward with policies and procedures but there was little to no empathy, and it was, they weren’t supporting me in – if you want his medical records, to see what happened, there was no sign postings for support or assistance. I spoke to the police officer who investigated it and he was the one who advised me, “If you want all this, put in a formal complaint”, and that’s what I did.
It shouldn’t take that. There was no open honesty.
Ms Pucks: Yes. In fact, sorry, I am just going to go back a step to the complaint that you made prior to his death: is that another example of where you made a complaint and then you actually did get a result, which was a CPA review?
Alan Oxton: Yes. But, again, that felt like that was on the back of a suicide attempt –
Ms Pucks: Right.
Alan Oxton: – and a serious one and then they suddenly thought, “Oh, we better do something”. By then, it was too late he was already on that steep downward trend.
Ms Pucks: Do you recall specifically what you complained about?
Alan Oxton: Yes. The lack – lack of support, them saying – the referrals, them saying no –
Ms Pucks: Right?
Alan Oxton: – we are not going to readmit him we are not going it treat him.
Ms Pucks: I would like to talk to you now about the lack of engagement in a little bit more detail after your father’s passing. Is it right that there came a time when you tried to speak to the ward in order to ascertain what had happened?
Alan Oxton: Yes.
Ms Pucks: Can you tell us a bit more about that? In what context did it happen and how did it happen?
Alan Oxton: I phoned them and wanted the answers of, “Well, was he being observed? Why did he have his belt?” All these sorts of questions you would ask, when I initially heard that he was under observation and then suddenly he’s managed to take his own life with his belt, all these sorts of things, why was – why – how could he barricade himself in? All these questions I put to them and there was no answer.
There was no reasoning behind it and it was just policies, procedures, he was on level 2 observations, he was watched every 15 minutes.
Ms Pucks: So there was no engagement with the questions that you actually asked?
Alan Oxton: No, they offered to come to my house, the one person, the Ward Manager, but it wasn’t – the discussion we were having wasn’t trending in the right way because I wanted the answers to why my dad had his belt, why he was able to barricade himself in the room, all these answers and they weren’t signposting me to where to get the answers. They weren’t giving me any form of support or assistance.
Ms Pucks: Did you also speak to staff to request medical records?
Alan Oxton: Yes.
Ms Pucks: Is that the same conversation or a different one?
Alan Oxton: That was the same person and, yes, I was informed that that wasn’t happening. So that’s when the police officer – because the police initially investigated it and they looked at it and it was closed off pretty quickly but – and then I highlighted this to the police officer and then it got re-investigated, and they held my father’s body back, so we couldn’t have the funeral for – it felt like ages, but I don’t know how long it was, and then when they closed it because they couldn’t investigate it, he said, “What you need to do is make a formal complaint to the Trust and that’s when you will get” –
Ms Pucks: A response.
Alan Oxton: – “a response”, and it shouldn’t have to take that.
Ms Pucks: No. Were you offered any – I think you have answered this question already: were you offered any support by the Trust, any emotional support or any other type of support following his death?
Alan Oxton: No. I – obviously, the incident was in April. I moved back to – initially no because I lived in Manchester. It wasn’t until I moved back to the area around about October – October time, that year, and I was treated as an outpatient. I was treated as an outpatient in Chelmsford because I refused to have treatment by Oyster Court, the Community Mental Health Team in Colchester, because I was – I had the issues with them, I had the complaint and I was going through the process with them over my dad.
So they referred me to someone in – and yes, the lady I spoke to was helpful, I got better and I got discharged. But I always kind of felt like it was – I don’t know, I struggled to trust them fully because I was identifying these trends and these issues with my dad’s care and I knew that they were the same people, the same Trust.
Ms Pucks: I have one more general topic with a few subheadings, which relate to investigations and inquests, and then I would like to move on to your recommendations if I may.
Now, there was a serious incident investigation that took place between July 2011 and November –
Alan Oxton: Yes.
Ms Pucks: Apologies July and November 2012. Now, this followed your complaint but were they linked, do you know?
Alan Oxton: Yes, I believe this was because of my complaint.
Ms Pucks: It was because of your complaint –
Alan Oxton: Yes.
Ms Pucks: – that the investigation took place?
Alan Oxton: I don’t believe it would have taken place. It didn’t feel like it was going to take place without a complaint. Suddenly my complaint kind of moved things on a whole step forward.
Ms Pucks: I understand, and you set out in your witness statement in some detail a summary of its conclusions?
Alan Oxton: Yes.
Ms Pucks: I would like to focus, if I may, on your views of this investigation. What impact, if any, did the investigation have on you?
Alan Oxton: To be honest, it raised more questions and issues than it actually answered, because I was – that’s where I found out about the belt, the level 3 observations being downgraded to level 2, this is where they interviewed all the staff, a number of staff had second interviews, and this is where they kind of tried to drill down into a person having a belt, there was no search, there was – sorry, I will re-word that.
This is where they identified that staff A said there was a belt and that they took it off him.
The Chair: The inconsistencies?
Alan Oxton: Yes, exactly. But they never drilled down and, like, they just left it, “Staff A says this, staff B said that”, and that just answered – that just asked more questions and more issues and, if someone said that to you about your loved one, “Oh, we don’t – he died with his belt, this person is saying he had it, this person is – or this person is saying he was searched and we took it off him, this person is saying we didn’t”, it just wanted – it made me want to know the truth because I kind of got half truths. I got – I could see where people were lying with the AMHP saying, “I can’t attend, I can’t transfer him because I have got to see someone else”, and later finding that not to be the case.
And I was, like, “What are you doing about this, are you holding them to account? What have you done because one staff member is clearly lying”. And, yes, it just unravelled and I found more questions and more things I wanted to I wanted answers to and it didn’t – it was no – in no way was it closure. It just raised more issues.
The Chair: At paragraph 28 of your witness statement, you set out the narrative verdict of your father’s death certificate –
Alan Oxton: Yes.
The Chair: – as:
“Mr Oxton’s risk of self-harm was correctly assessed but there was an incomplete transfer of the risk assessment resulting in a lower level of observation being applied. Mr Oxton was left in possession of his belt and the bedroom environment provided an opportunity to barricade the door and provided a point to achieve suspension.”
Do you have any concerns about this conclusion?
Alan Oxton: Yes. It felt like the inquest again was – didn’t seek to find the truth and they were made aware, the coroner, regarding this but at no point was there a desire to really investigate it and establish the full facts and what actually happened.
So I wanted the narrative verdict and I wanted the state to be held to account for it, which they were. But it still left those underlying questions about the transfer, the risk, the belt and the risk assessment being lowered without any form of assessment by a medical professional.
The Chair: So these questions were still unanswered, as far as you were concerned.
Alan Oxton: Yes, exactly, it just left them.
The Chair: Did you participate in your father’s inquest?
Alan Oxton: Yes. I – this is when I was undertaking the private or the civil claim with the Trust through my solicitors, who was Glynns, based in Bristol. They provided a barrister and I attended the inquest, yes.
The Chair: Do you remember whether any of the staff members gave evidence or were their witness statements taken as read?
Alan Oxton: No, there was no evidence given – informed of that and I was told that it isn’t a – the inquest wasn’t a – wasn’t to identify blame. It was just to identify, like, the facts and, like, the surroundings. But to identify that, you have to identify – to identify the facts, it seemed like that they – they stopped – they identified the facts to a point and then, when it started identifying blame, they stopped at that point to not hold people to account.
The Chair: Right. I would like to briefly touch on a few other legal proceedings before turning to your recommendations. As you have just mentioned, there was a civil claim that resulted in an out-of-court settlement; is that right?
Alan Oxton: Yes. That was purely and simply to get them to hold
them to account because I felt like the Trust didn’t
want to – there was never – the only time I – the
first apology I received from the Trust was after the
inquest and after the narrative verdict.
The Chair: Right.
Alan Oxton: And you would think that it would have been done sooner.
The Chair: In what form did you receive an apology from the Trust,
do you remember?
Alan Oxton: The Chief Executive come up to me after the inquest.
The Chair: Right?
Alan Oxton: Paul Scott, I believe his name – Scott was his surname.
The Chair: Yes.
Alan Oxton: And, yes, he apologised for what happened to my dad and,
yes. But it was a fairly – I was still upset from –
yes, I wanted the verdict that they were responsible but
it still didn’t give me the answers I wanted.
The Chair: Is it right that you also took part in Operation Ludlow
by Essex Police, which investigated corporate
manslaughter by the Trust?
Alan Oxton: Yes, it was, that was a large number of families and it
was investigating them for corporate manslaughter.
The Chair: Yes.
Alan Oxton: But that got to a stage where it was very hard it prove
corporate manslaughter because of the high threshold.
So then it got passed to –
The Chair: Was it the HSE prosecution?
Alan Oxton: Yes, the HSE one.
The Chair: You took part in the HSE prosecution; is that right?
Alan Oxton: I did, yes.
The Chair: Do you have any anything you would like to say about, about that?
Alan Oxton: Yes. They were – what really shocked me was the fine, was the sentencing, and that just kind of penalises the Trust even more to prevent it from doing good and restricting them funding-wise.
The only way I personally felt that there would be any sort of justice would be holding responsible the people who had failed him in the organisation, and those who had lied and those – those are the real people responsible and – yes.
The Chair: Thank you. At paragraph 35 on page 10 of your statement, you state that you felt let down by the investigations. Can you tell us more about why you felt let down?
Alan Oxton: Again, that was kind of – each time I would say to myself, “That’s it”, I would say, once – sorry, once I got the private civil claim out the way, “I have got the answers” – well, I didn’t get the answers, I got them to admit that they were in the wrong and I got the apology, so I would be like “That’s perfect”, that’s – well, not perfect, that’s – I was satisfied and then I would get drawn back in by another one, the policing one, and then I would be, “Well, I didn’t really get the answers there, so I will go for the HSE one”. Then they got fined, and I thought, “Well, didn’t really get any justice there, but they got found guilty”.
So then I would be, “That will be all I’ll do, I’ll end it there”, and then I found this. And then I was like, “Well, surely this time, I’ll say my piece for the however many times” – the inquest, the Serious Incident Report, the police investigation, the HSE, all these – “Surely, I will find out the answer to it this time”.
So this is why I am here again, to try and get those answers because all those other previous investigations and inquiries have failed.
The Chair: Thank you. I would like to now turn to the recommendations that you set out. They are at paragraph 36, page 11 of your statement. I wondered whether you would like to take them in turn and let us know what your recommendations are?
Alan Oxton: Yes.
The Chair: Thank you.
Alan Oxton: So:
“I believe the following changes need to be made to prevent the tragic deaths of those suffering from ill mental health in the future:
“Easier access to mental health services and a decrease in waiting times is required to allow earlier intervention.”
I believe my father, if he was seen sooner, when he was being re-referred, I said it may not – he may not – I am not saying he would have fully recovered and I am not saying he would be here today but that would have helped.
A wider range of talking therapies, not just – other than CBT – because that’s what he had – should be available and increase high quality psychologic therapies and specialist trauma.
Ensure seamless transition between primary care, so the GP and specialist mental health services. Again, that’s kind of going on from the GP referring him all these times and him not – him being rejected.
Crisis Resolution Home Treatment and mental health teams need to be properly resourced, so they can provide a level of care that is required.
Invest in mental health to improve the understanding of mental illness and develop more effective treatments and interventions.
Increased transparency between families and the Trust with regards to concerns about the quality of care provided.
In the event of a death, the NHS need to keep families informed as to internal investigations conducted and the outcome of these: have specific staff members been found negligent and what were the consequences. Again, you have got the issues that were raised – I have never been provided details as to what actually happened.
The Chair: Yes.
Alan Oxton: Provide accessible support for families and carers who provide vital roles supporting individuals with mental health.
Increased accountability for staff. Psychiatric negligence should be a criminal offence and those found negligible should be prosecuted.
The Chair: Yes. Do you have any further recommendations or observations that you would like to make –
Alan Oxton: No.
The Chair: – to the Inquiry at this stage?
Alan Oxton: No. I believe the HSE Inquiry, that my father was one of the – was one of the – I’m not sure whether it was Core Participants – and I believe in the verdict there was that was highlighted that there was another death –
The Chair: Yes.
Alan Oxton: – which was linked. I have not got the details to hand but I just would just like to highlight that as well, please.
The Chair: Yes, I believe you are referring to the sentencing remarks in the HSE prosecutions which referred to a death in very similar circumstances –
Alan Oxton: Yes.
The Chair: – some 18 months prior to your father?
Alan Oxton: Yes. I would just like to make that – just to make that aware to yourself that there was a similar death, similar circumstances 18 months previous, and my heart goes out it that family because they have suffered similar as myself. But it makes you think, well, if the recommendations were – if there were recommendations for that, they would have probably been very similar recommendations to my father’s – my father’s report and it could have been prevented.
Ms Pucks: Yes. Thank you very much. I have no further questions at this stage.
Chair, do you have any further questions?
The Chair: No, I don’t.
Ms Pucks: Thank you.
The Chair: Thank you very much for coming to give your evidence today. We appreciate it very much. Thank you.
Alan Oxton: Thank you for listening. Thank you.
Ms Pucks: Chair we do have a photograph of Mr Oxton’s
father, if I could ask for that to be played.
The Chair: And a younger you.
Alan Oxton: Just a bit!
Ms Pucks: Thank you very much.
Chair, I believe if we may rise for 10 minutes to
see whether there are any additional questions. If
there are additional questions we will return; if there
are none, then I believe we are adjourned until
tomorrow.
The Chair: 10.00 tomorrow.
Ms Pucks: 10.00 tomorrow, when we will hear from
Emma Sorrell and Lynda Costerd.
The Chair: Thank you. Thank you very much.
Ms Pucks: Thank you again.
(3.50 pm)
(A short break)
(The hearing did not reconvene)
(3.52 pm)
(The Inquiry adjourned until 10.00 am on Thursday, 10 July 2025)