Our reply to the Somerset Partnership – 27th January 2019

Dear Ms Paters,

Thank you for your response. However, I do not feel that it adequately deals with the issues I have raised.

Before my mum’s car accident, according to eye witnesses, she swerved back and forth across several lanes of the motorway before being hit by a lorry and subsequently hitting the central reservation. Being drowsie and losing concentration may cause a short lapse in concentration – but it does not seem plausible it would have caused the sort of behaviour that she exhibited, and which the mental health nurses who assessed her were aware of. Additionally, had the nurses fully read her notes from 2017, they would know that she was frequently untruthful about her intentions of self-harm. This, coupled with the nature of her accident, clearly should have raised her risk profile to the mental health staff involved, and I am not at all convinced the Trust have changed their procedure to ensure a similar patient would be safe in future.

Additionally, I have not at any point previously heard the mental health nurses involved, either at the inquest or in the notes provided to the inquest, claim that mum had said her accident was due to drowsiness. Is there any record of them doing so from their notes at the time?

My mum was seriously unwell, and had a history of lying about her intentions of self-harm. Therefore, whether or not she was happy with the outcome of the assessment is irrelevant. Additionally, my mum’s husband is not a mental health professional – it is not his job to assess risk, or to know whether an assessment had been carried out adequately. Whether or not he was happy with the assessment that took place is also in my view not relevant.

At the inquest, I found Mr Garlick’s testimony extremely concerning, as unlikely many of the other mental health nurses involved, he did not appear to have understood the mistake he had made, and did not appear to have reflected upon it to improve his own practice in future. For example, he cited my mum’s then upcoming house move as a ‘protective’ factor for her mental health, and said that this is what led him to believe she was not a harm to herself. He had not read in her notes that this was a stressor for her, and when confronted with this, still defended his decision making.

This is in stark contrast with many of the other mental health nurses involved, who when confronted with their mistakes, had admitted them and said they would not do the same in future. I am concerned that currently, if another patient in a similar situation to my mum was assessed by Mr Garlick, that they would not be assessed adequately – and therefore would not be safe. I do not want staff punished for what happened to my mum – but I am very concerned about the safety of future patients.

Unlike the Avon and Wiltshire Mental Health Partnership, the Somerset Partnership did not have any staff (as far as I am aware) at the inquest to listen to Mr Garlick’s testimony. This is extremely concerning to me, as it means the Trust are not able to use all of the information available to them to improve safety in future. Can I please ask whether the Trust have requested a copy of Mr Garlick’s testimony from the coroner? And if so, whether they have used it to assess if Mr Garlick requires any additional support or training?

If no additional training has been provided to Mr Garlick in light of his testimony, and if the Trust do not in response to my concerns raised here provide any, I will have to consider referring him to the Nursing and Midwifery council, and to escalate my complaint to the Parliamentary Health Ombudsman.

Best wishes,

Rebecca Montacute