Did much change? Not really. The 'Crisis Helpline' has been implicated in further PFDs by the same Coroner. Since then I have been working with other NHS Mental Health Trusts to produce learning resources to help clinicians to reflect on and learn from this and other similar deaths. It is, as you say, a vitally important matter.
A good summary of what should be an unarguable improvement to a much overlooked public service.
While not a criticism of the content, given the author's well documented views on the use of the adjective "clear" when describing political statements, one can't help but wonder if the author's subtitle describing the policy proposal as "sensible" is not unrelated. Surely every advocate of a policy feels their own policy to be sensible and a third party should surely be able to easily conclude on the senisbility of the policy independently without such assurances of this quality from the author, no?
Another bugbear of mine, however, are long-statements that have to be rescued by the addition of ", no?" at the end. If I ever become tempted to add ", no?" at the end of a statement, I go back and re-word it.
More sensibly (ahem), "sensible" is a word I should avoid relying on - see also "actually" and "really". And I will try to avoid it more often.
Yes, this positive duty to take action to prevent accidents or risk to life or injury is becoming stronger and subject to far greater compliance. “Reasonably foreseeable” acts//inaction/outcomes is allied to criminal law and it was Lord Lane who I had the pleasure to meet and spend time with who instigated changes in criminal law . A good case is the case involving throwing if my memory is correct, a brick from a bridge onto a car windscreen resulting in an accident where the driver died. There was no intention but the resulting act caused the death. To bring into modern times leading a walk now has its own strong requirements to prevent injury to walkers outlining potential risk such that volunteers are often reluctant. Such strong preventative and onerous duties create greater competence for training and competence of leaders in many industries and is certainly no walk in the park.
This is a good idea if and only if recommendations are reviewed to ensure they are sensible and proportionate. Our modern world already suffers from the curse of safetyism, where perceived safety considerations (not all of which are real) are elevated above other goods like joy, freedom, and dignity.
Some examples of how safetyism can go wrong, from the extremely serious:
- COVID-era school closures in which people focused on (very tiny) risks of children catching Covid and not on the much larger mental health impacts, effects of loss of education, and even safeguarding risks, as children were trapped in their homes with abusers and no prospect of schools or teachers raising the alarm,
- Depriving people locked in mental health wards of all dignity, autonomy, and privacy because they have tried to kill themselves. For example, locking people in featureless rooms for 23 hours a day, requiring them to be supervised even when showering or in the bathroom, totally denying them any chance to appeal this sentence. It doesn’t seem to occur to people that condemning someone to indefinite psychological torture is unlikely to improve their mental health and is a vile thing to do under any circumstances.
To the comparatively trivial:
- The public swimming pool that required one adult per two children if there was no lifeguard on duty, on the basis of no evidence except that ‘it seemed safer’. Result: families with three or more children were effectively excluded from enjoying the pool.
- Because one would-be terrorist once tried to put a bomb in his shoe, millions of people have to waste time and suffer aggravation from taking their shoes off in airports, with a combined total effect much longer than the expected lifespan of a plane full of people. Also, no one asks questions like “if you make planes perfectly attack-proof, won’t a determined terrorist just bomb something else instead? Are these measures saving lives or only changing who are the victims?”
What do these problems have in common? Ostensibly prioritising (at least one definition of) safety over anything else, ignoring trade offs, not admitting that there are other important things in life beside safety. In terms of incentives: decision-makers know they will get blamed and/or sued for any ‘safety incident’ but have no accountability for things like aggravating millions of air passengers. So they don’t ask what people would choose for themselves, or what increases human happiness, but only what is best for covering their backsides if anything goes wrong.
Let’s think about the unintended consequences before we propose yet another worthy body with a mandate to demand yet more rules and restrictions in the name of safety.
Investigate, report, apologise, ‘lessons will be learned, forget, repeat. Apologies for the negative comment, this is an important post.
Thank you for highlighting this issue. My daughter in law died in 2016. The Coroner issued a Prevention of Future Deaths (PFD) report. The NHS Trust produced a letter of response. (https://www.judiciary.uk/prevention-of-future-death-reports/mariana-pinto/)
Did much change? Not really. The 'Crisis Helpline' has been implicated in further PFDs by the same Coroner. Since then I have been working with other NHS Mental Health Trusts to produce learning resources to help clinicians to reflect on and learn from this and other similar deaths. It is, as you say, a vitally important matter.
Thank you for sharing this, and I am sorry for your loss. I will look at this report.
Thank you. I've blogged about this though not as succinctly as you do, e.g.
https://www.pslhub.org/learn/improving-patient-safety/safety-stories/by-patients-and-public/safer-outcomes-for-people-with-psychosis-r774/
Info on the project I'm working on is here
https://www.makingfamiliescount.org.uk/life-beyond-the-cubicle-project/
(I'm doing this as a volunteer btw...!)
Thank you, I shall read with interest.
A good summary of what should be an unarguable improvement to a much overlooked public service.
While not a criticism of the content, given the author's well documented views on the use of the adjective "clear" when describing political statements, one can't help but wonder if the author's subtitle describing the policy proposal as "sensible" is not unrelated. Surely every advocate of a policy feels their own policy to be sensible and a third party should surely be able to easily conclude on the senisbility of the policy independently without such assurances of this quality from the author, no?
Perhaps.
Another bugbear of mine, however, are long-statements that have to be rescued by the addition of ", no?" at the end. If I ever become tempted to add ", no?" at the end of a statement, I go back and re-word it.
More sensibly (ahem), "sensible" is a word I should avoid relying on - see also "actually" and "really". And I will try to avoid it more often.
Yes, this positive duty to take action to prevent accidents or risk to life or injury is becoming stronger and subject to far greater compliance. “Reasonably foreseeable” acts//inaction/outcomes is allied to criminal law and it was Lord Lane who I had the pleasure to meet and spend time with who instigated changes in criminal law . A good case is the case involving throwing if my memory is correct, a brick from a bridge onto a car windscreen resulting in an accident where the driver died. There was no intention but the resulting act caused the death. To bring into modern times leading a walk now has its own strong requirements to prevent injury to walkers outlining potential risk such that volunteers are often reluctant. Such strong preventative and onerous duties create greater competence for training and competence of leaders in many industries and is certainly no walk in the park.
Highly necessary in the USA, where corruption pervades all government offices.
This is a good idea if and only if recommendations are reviewed to ensure they are sensible and proportionate. Our modern world already suffers from the curse of safetyism, where perceived safety considerations (not all of which are real) are elevated above other goods like joy, freedom, and dignity.
Some examples of how safetyism can go wrong, from the extremely serious:
- COVID-era school closures in which people focused on (very tiny) risks of children catching Covid and not on the much larger mental health impacts, effects of loss of education, and even safeguarding risks, as children were trapped in their homes with abusers and no prospect of schools or teachers raising the alarm,
- Depriving people locked in mental health wards of all dignity, autonomy, and privacy because they have tried to kill themselves. For example, locking people in featureless rooms for 23 hours a day, requiring them to be supervised even when showering or in the bathroom, totally denying them any chance to appeal this sentence. It doesn’t seem to occur to people that condemning someone to indefinite psychological torture is unlikely to improve their mental health and is a vile thing to do under any circumstances.
To the comparatively trivial:
- The public swimming pool that required one adult per two children if there was no lifeguard on duty, on the basis of no evidence except that ‘it seemed safer’. Result: families with three or more children were effectively excluded from enjoying the pool.
- Because one would-be terrorist once tried to put a bomb in his shoe, millions of people have to waste time and suffer aggravation from taking their shoes off in airports, with a combined total effect much longer than the expected lifespan of a plane full of people. Also, no one asks questions like “if you make planes perfectly attack-proof, won’t a determined terrorist just bomb something else instead? Are these measures saving lives or only changing who are the victims?”
What do these problems have in common? Ostensibly prioritising (at least one definition of) safety over anything else, ignoring trade offs, not admitting that there are other important things in life beside safety. In terms of incentives: decision-makers know they will get blamed and/or sued for any ‘safety incident’ but have no accountability for things like aggravating millions of air passengers. So they don’t ask what people would choose for themselves, or what increases human happiness, but only what is best for covering their backsides if anything goes wrong.
Let’s think about the unintended consequences before we propose yet another worthy body with a mandate to demand yet more rules and restrictions in the name of safety.