Skip to main content

Suicide Risk Assessment Tools in the NHS

Volume 664: debated on Wednesday 4 September 2019

[Sir Christopher Chope in the Chair]

I beg to move,

That this House has considered the use of suicide risk assessment tools in the NHS.

It is a pleasure to serve under your chairmanship, Sir Christopher.

According to a detailed study carried out by Manchester University, in one year alone 636 people who were deemed by clinicians to be at low or no immediate risk of suicide went on to take their lives within the next three months. Of course, 636 is just a fleeting fact, one of myriad statistics about the NHS that we can cite every minute of the day, but every one of those 636 deaths is a tragedy—it is a brother, a friend, a partner, a child. One of those 636 people whose lives were lost in that year was the son of two of my constituents, a young man called Andrew Bellerby.

It may break the heart of any parent in this Chamber to see this photograph of young Andrew in his blazer as he went to school some years earlier. As one who proudly took my own children to their new school only this week, it is shocking to think that at some point one might lose one’s child in such circumstances. On 10 July 2015, many years after the photograph was taken, and in the same year as the study that I just mentioned, Andrew took his own life. The loss of Andrew’s life and the devastating impact that it had on his loved ones was, in all likelihood, totally needless. According to an expert witness who represented the Bellerby family, on a balance of probabilities Andrew would be alive today had the NHS trust that was entrusted with his care looked after him properly.

At this point, I would like to play tribute to Andrew’s family, particularly his father, Richard Bellerby. I understand that Richard’s brother is with us today in the Public Gallery; Richard could not be here himself, but I think that he is watching this debate via a parliamentary link. It was only due to his tireless efforts, his determination and his commitment to make sure that others do not suffer the same fate that we are debating this issue today.

Not only did the Bellerby family have to cope with unimaginable grief and loss, but they then had to fight a two-year battle with the Sheffield Health and Social Care NHS Foundation Trust to establish the truth. The truth, which the trust finally and begrudgingly apologised for, was that there had been a simple but fatal series of errors. Andrew’s state of mind was assessed by untrained nurses using an assessment tool—a checklist, for want of a better word—that was not fit for purpose. As a direct consequence, they made an incorrect diagnosis, without even taking into account his past behaviour.

First of all, I congratulate the hon. Gentleman on bringing this matter forward. In Northern Ireland, the figure for suicide is 20% higher than for the rest of the United Kingdom. Does he agree that it has come to the point that all frontline medical staff, from pharmacists to treatment room nurses, should be trained in appropriate suicide risk assessment, especially taking into consideration the high rate of suicide across the whole of the United Kingdom, and in particular in Northern Ireland?

The hon. Gentleman is absolutely right. That is one key component of three: training nurses; using a proper, validated tool; and taking into account the past behaviour of the individual and the context of the situation. None of those three things was in place for Andrew. As a consequence, 48 hours after being admitted to hospital in an ambulance, Andrew took his own life.

I am happy to give way to the chair of the all-party parliamentary group on suicide and self-harm prevention.

The hon. Gentleman is raising a very serious issue. I am grateful to Samaritans for a briefing on it ahead of this debate. It is absolutely clear that these risk assessment tools are not in themselves complete. They must be supported by consideration of the context, including previous history, and by a professional assessment of what is happening. Does he agree that it is absolutely essential that all trusts ensure that that happens?

I entirely agree with the hon. Lady. I know that the Bellerby family would very much like to meet the Minister here today—the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Mid Bedfordshire (Ms Dorries)—to see what can be done to make sure these situations do not happen again, and I think they would be very pleased to meet the hon. Lady, too, because I know that she does tremendous work in the all-party parliamentary group.

I will just add my point, from Scotland. In emergency departments, the staff have not been trained up to the level that we are hearing about today. Suicide is a big risk, especially among young people, and all we are asking for is that people look at this situation and give emergency staff the proper tools and training. If that had happened before, Andrew would be with us today.

The hon. Gentleman is absolutely right and I am grateful to him for his very kind contribution. I know that Andrew’s family will also be grateful to him.

The fact is that the Sheffield trust had been treating Andrew for many years; it knew him well and knew that he was a serious suicide risk, yet none of this was taken into account when he was admitted to hospital for that fateful final time. The untrained nurses carried out the assessment using a crisis triage rating scale, CTRS, and deemed Andrew fit to be discharged. They rated Andrew 14 on a scale of zero to 15, where 15 means that there is no serious or immediate risk of suicide, despite the fact that Andrew had a history of suicide attempts and also threatened to jump out of a fifth floor window while he was being assessed.

The insult to fatal injury in this case is that Mr Richard Bellerby has had to fight for justice and answers for years. He describes the trust’s role in this process as a campaign of dirty tricks—dirty tricks, denial and deceit. In February 2018, the trust finally admitted its wrongdoing, apologised and agreed to settle out of court, but before doing so it had persistently and gratuitously maintained that it was not at fault. For instance, the trust had said that it had an expert witness whose opinion was that whatever the trust would or could have done, Andrew would still have taken his own life. However, the trust refused to supply that expert witness’s evidence and it appears that such an expert never even existed.

The inquest established that the trust was guilty of missing numerous opportunities to provide help. The trust’s own internal investigation revealed that the nurses who had seen Andrew had no training in this area, which directly contravenes national guidelines. At the inquest, there was an embarrassing blame game between Andrew’s GP and the trust, with each pointing the finger at the other. As Mr Bellerby has said, it was like musicians in an orchestra playing from a different sheet of music, with no conductor.

There appears to be a complete lack of accountability; nobody has been properly held to account for these errors. The trust admitted in its internal investigation that it had failed to carry out adequate risk assessments. In Richard Bellerby’s profession, which is construction, failure to carry out proper risk assessment or failure to train people properly can lead to a charge of criminal responsibility for manslaughter in the event of a fatality.

Instead of being open and honest about the circumstances surrounding Andrew’s death, the trust only corresponded when it was forced do so. There were no responses to Mr Bellerby’s letters unless they were sent by recorded delivery, and even then the only responses came from corporate affairs managers rather than from clinicians, and they still failed to provide answers. The trust has not even responded to my letters, other than to send a holding response. I wrote to the trust on 28 January asking for answers to questions and I chased things up on 6 March, but there was still no full response. When the trust finally agreed to meet Andrew’s father, Mr Bellerby, it was of course a meeting with the corporate affairs director. When Mr Bellerby insisted on a clinician being present, the meeting was cancelled.

The trust refused simple requests for information, such as how long the nurses who saw Andrew had worked at the trust and what their qualifications were. The two-year battle cost the NHS around £40,000 just to reimburse the Bellerby family’s legal costs, in addition to any costs that the trust itself and NHS Resolution would have incurred. The total bill is likely to be in excess of £100,000—all for £9,000 in compensation. Critically, there was no compassion, no condolences and no remorse. Instead, there was contempt, denial and disregard.

To say the Bellerby family won is a travesty. They lost their son, a grandson, a brother, but they did defeat the trust. With the help of their solicitors, Irwin Mitchell, whose efforts were instrumental to their success, they won their case, they received their grudging apology and the trust has now stopped using the CTRS. All the family wanted was recognition of the failures and an apology. Given that, everything could have been sorted on day one. Instead the family had to fight against our own bureaucracy. It beggars belief that we tolerate a system that behaves in this manner.

Surprisingly, given the facts of the case and its role in the two-year cover-up of the truth, NHS Resolutions agrees with having a position of openness. In its 2018 report, “Learning from suicide-related claims”, it states:

“Where compensation is due it should be given willingly and in a timely manner to prevent further distress and suffering to distraught families.”

It is time we lived up to those fine words.

The Bellerby family have worked closely with Manchester University on the inquiry I mentioned earlier, which is called, “The assessment of clinical risk in mental health services”. It has helped to establish the extent of the problem of inappropriate use of suicide risk assessment tools in the NHS and the figure of 636 deaths per annum. It has also established that today, 33 out of 85 trusts use a tool that has not been independently validated and 29% of trusts use it with untrained staff. The national inquiry into safety in mental health recently raised issues of the

“inconsistency across mental health trusts in the length and content of risk assessment tools”

and a

“variation in how tools are used and examples of use contrary to national guidelines”.

Everyone seems to agree that the incorrect use of such tools is wholly wrong. Mental health charity Mind is clear that the Government should standardise tools across the service, improve training and support in their usage and follow-up within 48 hours with those who have received assessments. The Royal College of Psychiatrists said that we should

“move away from a risk assessment model to a risk reduction model”.

I know the Minister will be appalled by the full details of the case and will be determined to help drive change in the system, and I have some questions for her. What has changed since Andrew’s death? Specifically, what action will she take to ensure that mental health trusts are only using risk assessment tools that have been independently validated as safe? What action is she taking to ensure that staff in mental health services receive training in risk assessment? What action is being taken to support staff to be able to talk to people about suicidal thoughts? Will she implement a process so that the Care Quality Commission or another body can check that best practice is adopted? Will she commit to an ambition for zero suicides among all those under the care of mental health services? Will she look at the behaviour of the trust and drive through a new policy of openness and honesty in our health services? Finally, will she meet me and my constituents to hear Andrew’s story and possible solutions at first hand, to ensure that Andrew did not die in vain?

It is a pleasure to serve under your chairmanship, Sir Christopher. After 10 years of being a Chair myself, I hope I do not incur your wrath today.

I thank my hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake) for securing this important debate. It is an honour for me to take up the position as Minister with responsibility for suicide prevention. My predecessor, my hon. Friend the Member for Thurrock (Jackie Doyle-Price), did a commendable job when she held this position and I am determined that we continue to do whatever we can to reduce the devastating impact of suicide.

I offer my sincere and heartfelt condolences to the family of my hon. Friend’s constituent. I welcome Robert Bellerby to Westminster Hall and thank him for coming today. These will continue to be difficult times for the Bellerby family. I know from personal experience how devastating it is to lose someone you love and someone who is close to you through suicide. It is inspirational for me to see the courage and determination of those, such as Mr Bellerby, who manage to bring about positive action from such tragic circumstances. By their actions, Mr Bellerby and others like him will help to prevent others from going through the same deep and lasting loss.

I will now turn to the specifics raised by my hon. Friend about the use of risk assessment tools for patients at risk of suicide. He raised the specific case of Andrew Bellerby, who sadly died in 2015. I understand that at the time of Andrew’s attendance at hospital, it was practice at the Sheffield Health and Social Care NHS Foundation Trust to use a crisis triage rating scale tool. It was used to assess Andrew before he was discharged. Sadly, he took his own life shortly after. The trust conducted a serious incident review to learn the lessons from this tragic case.

It is clear that the care Andrew received leading up to his death was not satisfactory, and I understand that a comprehensive action plan was developed and fully implemented by the trust following the serious incident review. I have also been reassured that the trust has stopped using the crisis triage rating scale tool, following a report published by the national confidential inquiry into suicide and safety in mental health in 2018, which recommended that the risk assessment tools should not be used as a way of predicting future suicidal behaviour.

I recognise and share my hon. Friend’s concerns about the use of risk assessment tools across the wider NHS. He is right that guidelines published by the National Institute for Health and Care Excellence make clear recommendations that NHS professionals should not use risk assessment tools and scales to predict future suicide or repetition of self-harm, or to determine who should be offered treatment and who should be discharged. Each NHS trust is responsible for the care it delivers and the safety of its patients. but NICE guidelines are clear on the use of risk assessment tools, and we expect the NHS to implement the guidelines. Clinical guidelines represent best practice and should be taken fully into account by clinicians.

The national confidential inquiry into suicide and safety in mental health has published “Safer services: a toolkit for specialist mental health services and primary care”, which presents 10 ways to improve safety. NHS England has supported all mental health trusts to access the toolkit, which includes guidance for trusts on the use of risk assessment tools and highlights NICE guidance. The toolkit specifically states:

“All patients’ management plans should be based on the assessment of individual risk and not on the completion of a checklist.”

The hon. Member for Blaydon (Liz Twist) was absolutely right that the situation should be put in its context as it presents at that moment. Everything, including the history of physical and mental health, should be considered when assessing and evaluating a patient when they present with a potential suicide.

I am pleased to hear that the Minister is focused on ensuring that NHS trusts apply the guidance. What steps will she take to ensure that that happens across the board?

I am delighted to inform the hon. Lady that just this week, NHS England has written to all mental health trusts to make clear that they should be adhering to NICE guidelines on the use of risk assessment tools. My hon. Friend the Member for Thirsk and Malton mentioned a trust that is still using the old method. As a result of this debate, we have ensured that the letter is going out to tell NHS trusts that they should not be using the tools any longer and should be implementing the NHS guidelines.

I congratulate the Minister on her appointment. When intervening on the hon. Member for Thirsk and Malton (Kevin Hollinrake), I referred to the 20% increase in suicides in Northern Ireland. I did so because it is factually correct, and because in Northern Ireland we have a policy and strategy in place to address those issues. Has the Minister, in her short time in her role, had the opportunity to discuss those matters with, for instance, the Northern Ireland Department of Health?

I am afraid I must disappoint the hon. Gentleman. This is my third day in, and I have not yet had a chance to discuss Northern Ireland in detail, but as a result of his intervention I will ensure that we do that, and it will be on tomorrow’s agenda.

The letter that NHS England sent out highlights the report from the University of Manchester on “The assessment of clinical risk in mental health services”, and asks trusts to ensure that their risk assessment policies reflect the latest evidence from the university, as well as best practice. I am pleased that NHS England and NHS Improvement have committed to working with trusts to improve risk assessment and safety planning as part of future quality and safety work on crisis care and suicide prevention.

My hon. Friend the Member for Thirsk and Malton asked specifically about the role of the Care Quality Commission in ensuring that trusts are adopting best practice in respect of risk management processes. The CQC has assured me that risk management processes are a key feature of every CQC inspection. I hope that that assurance from the CQC, along with the letter that NHS England sent out this week, will go some way to reassure my hon. Friend.

I am sure that the work that the Minister has already done to raise the issue with trusts is very positive news for the family. On the basis that people do not do what is expected but what is inspected, it is good to hear that some processes are already in place in the CQC. Will new processes be added? Presumably checks were happening when the situation occurred, so we need something else to ensure that best practice is properly adopted.

If I may continue my speech, I hope that I can reassure my hon. Friend on that point.

The Government are committed to a culture of openness, honesty and transparency in the NHS. The legal duty of candour means that trusts need to be open and transparent with patients or their families when something appears to have caused, or could lead to, significant harm. Trusts could face action from the CQC if they are seen to be failing to comply with that duty. I think that some good news will come out later in the year that will hopefully reassure my hon. Friend regarding a new culture that will develop within the NHS to encourage staff and clinicians to be more open about incidents as they happen, so that they share information and we can learn from such incidents.

Our national learning from deaths policy has introduced a more standardised approach to the way that trusts review, investigate and learn from deaths. The national guidance on learning from deaths, published in 2017, is about supporting trusts to become more willing to admit to and learn from mistakes, so that they reduce risks to future patients and prevent tragedies from happening in the first place. The guidance is clear that trusts must engage meaningfully and sensitively with bereaved families and carers as part of that process. I hope that, as a result of those measures, what the Bellerby family went through in 2015 will never be experienced by another family. To support our national policy, the CQC has strengthened its assessment of learning from deaths by trusts.

I will talk about what we are doing to reduce suicides across the NHS more widely. People in contact with mental health services account for around a third of all suicides in England, and arguably some of the more preventable ones. The overall suicide rate among people in contact with mental health services has reduced significantly over the last decade, but numbers remain too high. We must not lose sight of the fact that nobody under the care of NHS services should ever lose their life as a result of suicide. At the start of 2018, we therefore launched a zero suicide ambition, starting with mental health in-patients, but asking the NHS to be more ambitious and look to expand it to include all mental health patients.

I know it is only the Minister’s third day, but the thing that we ask for more than anything else in a Minister is for somebody who cares about their portfolio. It is clear that my hon. Friend really cares about this issue. I am not unique in this, but as one of the few Members who has used NHS mental health services, I can attest to the real value and life-saving contribution that they make. I commend her decision to have that aspiration for zero deaths from suicide in the NHS.

In my constituency, there were 10 suicides last year. That is 10 families ripped apart and hundreds of lives broken as a result of those tragic decisions. Key to a brilliant service is the number of NHS nurses out in the community. Will the Minister, as she develops in her role, look at the numbers on the ground, so that we can be sure that everybody in our constituencies has access to mental health nurses, who can save lives?

I hope that I can reassure my hon. Friend on some of those points as I whizz forward. We have asked all mental health trusts to put zero suicide ambition plans in place. As already outlined, NHS England is providing funding for suicide prevention to every local area, which includes investment in a national quality improvement programme to improve safety and suicide prevention in mental health services across the NHS.

We are also investing £2 million in the Zero Suicide Alliance, which aims to deliver an NHS with zero suicides across the system and in local communities. It is doing that through improved suicide awareness and prevention training, and developing a better culture of learning from deaths by suicide across the NHS. In June, the then Prime Minister announced that we would encourage all NHS staff to undertake the Zero Suicide Alliance training, which makes all NHS staff more aware and gives them a basic understanding of how to recognise when somebody may be in the space of wanting to take their own life.

My hon. Friend the Member for Thirsk and Malton may be aware that yesterday the Office for National Statistics published the final suicide registrations data for 2018. Concerningly, there were substantial increases in the suicide rate amongst the general population, following three consecutive years of decreases. The latest figures are disappointing, but reinforce why suicide prevention continues to be a priority for the Government and for me personally.

Experts are clear that we need more data to draw firm conclusions from the latest data, and we will continue to work closely with academics and other experts to consider the data in more detail. There has also been an issue over the past two accounting periods surrounding coroners and the way the reporting of suicides takes place. We continue to take action to reduce the devastating impact of suicide. Every local area has a suicide prevention plan in place, and we are working with the local government sector to ensure the effectiveness of those plans. NHS England is also continuing to roll out funding to every local area to support suicide prevention planning.

We are continuing to improve mental health services. Under the NHS long-term plan published in January, there will be a comprehensive expansion of mental health services, with an additional £2.3 billion in real terms by 2023-24. Crisis care is a key element of the plan, which commits to ensuring that by 2023-24 anyone experiencing a mental health crisis can call NHS 111 and have 24/7 access to the mental health support that they need in their community.

We will set clear standards for access to urgent and emergency specialist mental health care. That will be supported by further mental health crisis care services by 2023-24, including 100% coverage of 24/7 crisis provision for children and young people, 100% coverage of 24/7 crisis resolution, and home treatment teams operating with best practice by 2021 and maintaining coverage to 2023-24. We are also investing £249 million to roll out liaison mental health teams in every acute hospital by 2020, which I hope addresses the question my hon. Friend the Member for Thirsk and Malton asked earlier, to ensure that people who present at hospital with mental health needs get the appropriate care and treatment that they need.

To conclude, I again extend my sincere and heartfelt sympathies to the Bellerby family and friends. I assure them that we are doing everything that we can to prevent further suicides, as we understand their devastating impact on families and the communities affected. I thank my hon. Friend again for raising this very important issue. I would be happy to meet him, and Mr Bellerby and his family, to discuss their concerns in more detail.

Question put and agreed to.