AS staff members of NHS Scotland we would like to comment on your article “Man who took own life was ‘refused help repeatedly’” (April 5). We are disappointed that not only such a headline but much of the content describes our mental health services as being in failure without any further qualification or comment from NHS Scotland mental health professionals.

Every suicide is a tragedy, and we want to express our deepest sympathy for the families and friends of Luke Henderson and David Ramsay. As clinicians

we are unable to comment on these patients as we have no knowledge of the details of the presenting problems. We can, however, comment on general mental health care in Scotland.

NHS Scotland staff are working diligently to prevent these tragedies. But every completed suicide is also confronting us with the fact that somewhere in this system a mistake may have happened. And in each of these tragedies we owe it to the bereaved families, carers and friends of the person to find out and be open about what exactly has happened. Critical Incident Reviews are statutory for each person who has completed suicide and has been in care of NHS services. Required changes in services are implemented following these reviews. Also in some cases the Mental Welfare Commission will get involved to further investigate. Statutory review processes are therefore already in place.

It is disappointing that your article creates the impression that our “mental health service is not fit for purpose”, that patients are “being turned away and abandoned” and that “the same failures are happening up and down the country”. This is simply not the case.

If a person is not already known to mental health services, we can see no circumstance where a patient would be denied specialist mental health assessment. In all cases of acute suicidality hospital admission will take place, either voluntary or if need be against the will of the patient under a section of the Mental Health Act Scotland.

This, however, changes when the person is already well known to general mental health services or other specialist services.

Here, as clinicians we are frequently confronted with situations where a hospital admission may actually be contraindicated. Following specialist assessment, clinicians have to make the most difficult decisions, often distressing for patients, families but also for the clinicians themselves.

We would like to give a few examples of the complexity of situations where admission to hospital may be more harmful than helpful:

  • People with certain psychological disorders will experience frequent and repeated crises with thoughts of self-harm/suicide. Whilst initially those patients will receive hospital admission, over time repeated admissions will prevent patients from acquiring the skills to cope with those crises and create dependency on hospital. Prolonged or frequent hospital admissions can be especially damaging for younger patients.
  • Patients with addictions can repeatedly present with suicidal ideation, often caused by the nature of the addiction and the socioeconomic consequences of their addiction. In situations like these, and following assessment, alleviating the problems, ie supplying food bank tokens, referral to homeless/welfare services and continued support from alcohol and drug recovery services etc are the indicated interventions.
  • We sometimes see patients who feel that they have no choice but to escape from difficult social circumstances by seeking admission to hospital, instead of being able to use the indicated support services in the community.
  • For some people acts of self-harming, such as taking medication overdoses or cutting themselves, can be attempts of coping with crisis without actually wishing to end their lives. This can much better be addressed in the community, for example with specialised psychological therapies.

Clinicians need to take these and many more factors into account when making a decision if to admit a person to hospital or not.

From the description of events given by Karen McKeown in your article we can only assume that both Luke Henderson and David Ramsay had been known to NHS mental health services, and that clinical considerations similar to those above may have played a role in the decisions not to admit them to hospital. These are very difficult decisions to make, even for experienced mental health staff, and sometimes even events that are unforeseeable at the time of assessment can result in a patient taking their own life. We feel deep sorrow about the outcome in all cases of completed suicides.

The article leaves the reader with the impression that across Scotland clinicians are not weighing up painstakingly whether to admit to hospital or not, that they are discounting significant mental health symptoms, that concerns of relatives and friends are being routinely dismissed, and patients are being turned away carelessly from services. This couldn’t be further from the truth.

It is sad to see that such tragic circumstances are being politicised by the opposition parties. We are also concerned that this negative and inaccurate description of our mental health services could actually discourage people in crisis to seek the help they need and it does great disservice to staff working in NHS Scotland.

It is, however, important that any recommendations for improvements in mental health services that may result from the Critical Incidence Reviews are implemented.

Ulrich and Mohrag Fischer
Torrance