FAILURE IN CARE: The long Road To JUSTICE For ALICE

In this episode of 'Stories, Labels, and Misconceptions,' hosts Val Barrett and Dr. Jeremy Anderson discuss the tragic case of Alice Figueiredo, a young woman who died by suicide in a secure mental health ward in 2015. The discussion covers the court's recent verdict holding NHS frontline staff and the trust accountable for Alice's death, various systemic failures, and the implications for mental health care in the UK. 

They also explore the importance of accountability, common sense in risk management, and the critical role of families in mental health assessments. This episode raises crucial questions about the state of mental health care and the changes needed to prevent such tragedies in the future.

📧 Email us: storieslabelsandmisconceptions@gmail.com

🎵 Music: Dynamic
🎤 Rap Lyrics: Hollyhood Tay
🎬 Podcast Produced & Edited by: Val Barrett

⭐ Please leave a review
📲 Follow us
🙌 Get involved

📝 Please take The Survey to help us improve our content and strengthen our connection with you.
🙏 Your participation is greatly appreciated!

Transcript

INTRO RAP: [00:00:00] Stories, labels, Misconceptions, NHS remains a blessing. Created in 1948, we want it to remain great. A podcast where we share our stories, explore solutions in all their glories. They say it's broken, but it's not done, with your host Val Barrett and Dr. Jeremy anderson.

Val: How does a young woman make 18 previous self harm attempts with the same item on her on an NHS ward and no one removes it. And how does it take 10 years to reach justice? Welcome to Stories, Labels and Misconceptions with me [00:01:00] Val Barrett.

Dr Jeremy: I'm Dr. Jeremy Anderson.

 Dr Jeremy: Today we're talking about a very sad case a jury reached a verdict holding an NHS trust and frontline staff responsible for the death of a young woman, Alice. Figueiredo she died by suicide in July, 2015 in a secure mental health ward. She made 10 prior suicide attempts, and 18 self harm attempts, I'm just responding to the news article that I've read so neither of us, watch the trial or have any particular details there.

Based on what's been reported, it's a very unusual case where frontline staff in NHS Trust have been held responsible for a patient's death. It's not unusual for patients to die in hospitals. This is where sick and dying people go. We expect people to die. On mental [00:02:00] health wards the whole reason people get admitted to mental health wards given the pressures in the system is, the most severe cases, the most at risk, the people who are at risk of killing themselves or someone else are the people who get admitted or to mental health wards.

So we do expect some people to die but it's very rare you say the staff involved were so negligent or the trust was responsible. They've sentenced the ward manager to six months in jail, suspended for 18 months. Probation, but if he violates any conditions he would be put in jail for six months. The trust has been fined over 500, 000, including 200, 000 in legal costs the parents of this young woman have taken the trust to court for the last 10 years. And so I, I guess just before I hand it over to you to give some of your reaction, I just want to say, nothing that either of us say in this podcast is really meant to disparage either Alice or her parents [00:03:00] or question the verdict reached by the court but just my own reaction. I find this to be a really interesting case because it is so unusual. 

Val: What's a bit sad 

Dr Jeremy: yeah. 

Val: Both the defendant what's his name? Aninakwa I can't pronounce 

Dr Jeremy: his name. I'm gonna take a stab. It's Benjamin Aninakwa

Val: Benjamin Aninakwa 

Dr Jeremy: Aninakwa 

Val: Sorry, 

Dr Jeremy: sorry. 

Val: The defendant and the trust. 

Dr Jeremy: Yeah. 

Val: Denied wrongdoing, declined to give evidence. 

Dr Jeremy: Yeah. 

Val: After 10 years. The family waited and declined to give evidence. You would have thought, give the parents something. 

Dr Jeremy: Yeah 

Val: It's on top of that disrespect of declining to give evidence. No matter what the judgment was, they just [00:04:00] didn't. Says a lot. 

Dr Jeremy: You 

Val: There's never been a trust or person held accountable this way before. It's hopefully a wake up call for other trusts that take care of the vulnerable as well.

To know , that Alice, was there to be taken care of and for them to know that she already attempted self harm, I think suicide as well, with plastic, this is nothing new, that was nothing new. And then, for her to have that plastic, because they didn't remove it. 

Dr Jeremy: Yeah. 

Val: Do you see what I mean? Yeah. From what I've read, she was the only person on the ward that had attempted to take her own life. 

Dr Jeremy: She was the only person?

Val: [00:05:00] Oh. The judge remarked that as well. The judge said, you knew she was suicidal. She was the only patient on the ward that was. Your negligent breach of duty went on for weeks. The suicide attempts were recorded in ward notes and other hospital notes. Judge Mark said, I am in no doubt there was a complete failure to adequately assess and manage the risk she had used plastic from the toilets to self harm at least. 10 Previous Occasions. 

Dr Jeremy: The article doesn't articulate what this plastic was?

Val: During her time in the psychiatric ward, the trust failed to remove plastic items from the communal toilets or keep them locked. 

Dr Jeremy: Doesn't describe. 

Val: It doesn't. 

Dr Jeremy: Yeah. There's a few things you could imagine people [00:06:00] doing, but the reason I mentioned is, obviously this whole situation is a tragedy. She's got heartbroken parents and anyone reading this story gets an emotional response. The reason I mentioned that is what we know in psychology is that when we feel very emotional about a thing, 

Val: yeah, 

Dr Jeremy: it's easy to forget that, when something happens, multiple things. Contribute when it elicits a lot of emotion, we tend to focus on one cause and we imagine that's the one thing that caused it, right? Whereas there can be many things involved. 

Val: I know what you're saying, but I think one of the main things was that the plastic was never removed.

Dr Jeremy: Yeah, if she used this plastic item to take her own life, then clearly that was that was relevant. 

Val: Oh, she used a bin bag. 

Dr Jeremy: A bin bag. 

Val: Yes, so perhaps all they had to do is not have bin bags [00:07:00] and throw the rubbish In a bin with no lining, 

Dr Jeremy: not a 

Val: big deal, is it?

It's not. 

Dr Jeremy: Or lock the toilet, lock the room. So even if the bin has a liner, a suicidal patient doesn't have access to that room, right? 

Val: But, even, okay let's say In your home. 

. 

Val: You've got junkie. 

Dr Jeremy: Yeah. 

Val: Said it . 

Dr Jeremy: Yes. 

Val: Perfect. He had a penant for eating plastic. 

Dr Jeremy: Yes. 

Val: You 

Dr Jeremy: make anything off the ground?

Val: No. Let's stay with plastic. 

Dr Jeremy: Sure. 

Val: You would make sure you would, that you wouldn't be using any. If he went after bin bags, you would rather empty your rubbish in a bin with no lining and wash that bin out. You would rather that, because you can't watch him 24 7. So you would make sure, if there's yoghurt left over, you throw it in the bin. All you've got to [00:08:00] do is wash it out. 

Dr Jeremy: That 

Val: No, it's not. You've eliminated that threat. Some things just take 

Dr Jeremy: yeah. 

Val: Common sense. 

Dr Jeremy: Yeah.

Val: That's all it does, when you have a baby. We buy things to cover electric sockets, so they don't put fingers in it. We put rubber stuff at the end of hard tables. So when they knock themselves, it doesn't hurt as much. We eliminate threat risks. We look at health and safety risks in the home because we know. A lot of things happen in the home. 

Dr Jeremy: Yes, of 

Val: course. So when we have young kids, we think, okay, we need to cover up that. To me, I'm not saying it might not have happened, but The fact they didn't do that says a lot,

Dr Jeremy: yeah, I think [00:09:00] what's resonating with me is I'm trying to figure out why put myself in the shoes of someone working on that ward, you mentioned the idea, if someone has self harmed 18 times. 

Val: Yeah. 

Dr Jeremy: The court took that into account.

She's made previous attempts. The common sense idea is if someone's made previous attempts, they're really at risk, right? So you should take steps. 

Val: They knew that. 

Dr Jeremy: And they already knew that. But I wonder, if you knew someone who said, I feel suicidal and they've made 18 non lethal attempts. How suicidal are they really? They're distressed. But, I've had experience with many patients who have said that, they're suicidal or they feel like dying.

Val: Yeah. 

Dr Jeremy: It's not really black or white, either you are suicidal or not. It's saying, I feel I want to die. People talk like that all the time. Everyone has probably said something like that, right? 

Val: The difference being. 

Dr Jeremy: Yeah. 

Val: She was in a [00:10:00] psychiatric ward. 

Dr Jeremy: Exactly. 

Val: That should make a slight difference. 

Dr Jeremy: Yeah. What I'm saying is there's a spectrum of, people say, but they don't really mean it. 

Val: Oh, yeah. 

Dr Jeremy: Then there's people who say, who are saying, I feel like I'm suicidal. And they are having thoughts of suicide. And they are thinking, maybe it's not active, maybe it's passive. They don't want to do anything, but if they died, it wouldn't bother them, right? That's one level. And then there's people who are, who actively intend, they may not know how to, they would do it, but they really do want to die. And then there's people who've thought about it and have a plan, but maybe their plan isn't very lethal. I talked to a guy who said he made a number of suicide attempts, I asked what he did, and he said he sat in a snowbank. 

Val: He sat in what? 

Dr Jeremy: In a snowbank. 

Val: What is that? 

Dr Jeremy: In Canada. When you have a giant pile of snow because it snows a lot. 

Val: Yeah. 

Dr Jeremy: His idea was to dig a hole and sit in the [00:11:00] snowbank. If you stayed there long enough overnight you'd get hypothermia and die. But clearly he hadn't, because sitting in a snowbank, what he was calling a suicide attempt, is not a very lethal. And there's lots of ways that people will say, okay, I was, they might have intended to kill themselves, but their method is not very lethal. And then of course, there's people who are both very committed. They intend to die and their chosen method is very lethal. So if we think about this case, clearly she was self harming quite a bit. And she may have made suicide attempts, it seems, ten of them previously, but they weren't that lethal because they hadn't worked, right? The ten previous suicide attempts didn't work. 

Val: The next one did. 

Dr Jeremy: But the next one did, right? 

Val: All it takes. 

Dr Jeremy: That's the scary part I had a patient who came zonked out. She had been taking handfuls of pills. She didn't want to live. She said, if you let me go home, I'm just going to take more [00:12:00] pills and kill myself. 

Val: Okay. 

Dr Jeremy: Now taking those pills. Not very lethal, but possibly lethal. Scary, because on some level, I don't think she wanted to die. But it's possible to not really want to die, but do something that's just lethal enough that you commit suicide by accident. So you have to take it seriously. What I did was, we went downstairs and walked to the emergency room. I brought her there.

Val: Okay. 

Dr Jeremy: The emergency room didn't do anything. They just said, sit over there. Called her husband and that's it. But the healthcare staff who deal with this stuff on a routine basis. They get pretty callous, pretty jaded. They don't take it seriously. They see it all the time where someone says, I'm suicidal. They especially in an A& E, they just have a feeling like, we're here trying to save people who want to live. So we don't have time to deal with people who don't want to live. 

Val: We know Alice had bipolar [00:13:00] and an eating there was a lot going on. 

Dr Jeremy: Yeah. 

Val: She wouldn't be there for no reason. 

Dr Jeremy: Yeah. 

Val: She's in there to be taken care of I don't know how it works because I don't know about psychiatric care. I don't know if they, once they go in, if there's treatment and then they come out, I don't know.

Dr Jeremy: Yes, and we don't know the details of was she in there just for a three day assessment or for long term treatment? I don't know. 

Val: Okay. 

Dr Jeremy: I'll tell you another story. I used to do risk assessments for jails in Canada. When people are admitted to a jail, you want to assess, whether they're at risk of harm to themselves, or if they're at risk of harming other inmates, or if other inmates will prey on them and, harm them. So I used to do that quite a bit. And then where I was living, a new jail that was built. But the warden [00:14:00] who's heading up to jail had a hate on for psychology, didn't want any kind of psychology assessment. 

Val: Really? Okay. 

Dr Jeremy: Just thought this is a waste of time and money. 

Val: Huh. 

Dr Jeremy: And the way they had built this jail is the units, the bedrooms, where inmates sleep opened up onto a common area. The upper level had a railing and a drop. Within weeks of this jail opening, inmates figured out they could tie their clothing and bedsheets around a pole. 

Val: Yeah. 

Dr Jeremy: They could tie the restaurant on their neck, run, jump over the railing.

Val: Oh. 

Dr Jeremy: There were a number of suicides immediately because of the way this jail was built, they didn't have any assessment mechanism to determine. whether people wanted to die or not. 

Val: That's sad. Anyway, 

Dr Jeremy: It was very sad. When you take these precautions, one of the things that happens is you feel, if you actually prevent suicides, what you get is the sense that we're doing all this work to prevent stuff.

No one ever kills themselves maybe it's because you're actually preventing the deaths. But staff [00:15:00] might be left with the sense that this is all much ado about nothing, right?

Val: Oh, okay.

Dr Jeremy: And people start to be lax with procedures. I think if, I'm trying to put myself in the shoes of the staff if you think, okay, we got someone who says they're suicidal and they've made a whole bunch of attempts, but nothing's happened. Probably not a huge risk. No big deal. Then she completed suicide.

Val: The trial took 10 years. 

Dr Jeremy: Yeah. 

Val: From the time Alice died to the sentence in. June 2025. N E L F T, stands for, trying to find out what it stands for. You 

Dr Jeremy: This is the trust. 

Val: So in June, 2025, the manager, Benjamin Aninakwa

Dr Jeremy: Oh. Aninakwa 

Val: They were found guilty of health and safety breaches. 

Dr Jeremy: Yeah. [00:16:00] It's rare that frontline NHS staff and trust are held legally accountable. Another thing that was deliberated for weeks, one of the longest. in English legal history.

Val: That's a long time. 

Dr Jeremy: Yeah. So it really is a complicated issue that, I'm sure they had lots to discuss and evidently, they at least at the beginning of deliberations, they couldn't have been in agreement. Otherwise it would have been a shorter deliberation. 

Val: Then there's also guidelines, how the judge directs them. Don't they give them questions? If you come to X, Y, Z, then he's guilty of blah, blah, blah. You and I weren't in the courtroom. 

Dr Jeremy: Yeah. 

Val: We have no idea. , No clue.

Dr Jeremy: Yeah. 

Val: But he was given a six month suspended sentence plus 300 hours community service. Judge Marks took into account The 10 [00:17:00] year delay in his decision to suspend the jail sentence. It's not like he was on remand. He was living his best life. I, that's the part I don't get. For the case to take 10 years, That's irrelevant.

To me, the people that suffered more in that 10 year wait was her parents, not the defendant. 

Dr Jeremy: Yes,

Val: Do you see what I mean? 

Dr Jeremy: Of course 

Val: parents were suffering. We've got to remember the person who has died. It's about them. But when they've gone, it becomes about the person on trial. I find that hard to swallow. Even if he went behind bars for three months, give the parents something. Give him something more. 

Dr Jeremy: Yeah 

Val: Her life accounted to something. They said he was guilty. Some things, require a suspended sentence. To me, 10 year delay or [00:18:00] not, no. He should have gone to jail. Life has been lost. When Awaab died, there's no accountability here. There isn't. 

Dr Jeremy: Yeah. 

Val: I don't care about the money. How much the trust gets fined or whatever. There's no accountability, especially as the judge, he was guilty. There should be, 

Dr Jeremy: Yeah 

Val: Should have been behind bars. Should have seen inside of a jailhouse. Should have done. 

Dr Jeremy: Yeah. This is probably a good place to bring up. Obviously there has to be accountability when people. Are lax and tragedies, occur as a result. I was thinking though about what is the unintended consequence of these kinds of decisions? Not to suggest for a moment that this was the incorrect decision, but what are all the ways that this will affect the NHS? Frontline healthcare workers, or people working in mental health as a result [00:19:00] of this case, because again, it is rare, 

Val: I don't think it will now. Now I've thought about it. 

Dr Jeremy: Yeah. 

Val: I don't think it will. I'm going to change tack. 

Dr Jeremy: Yeah. 

Val: You remember all the police in America. 

Dr Jeremy: Yes. 

Val: Especially on African Americans. It wasn't until George Floyd that somebody served time. Then there was another case. 

Dr Jeremy: Yes. 

Val: We saw on camera this police stop and the woman shouted Taser and she pulled her handgun and shot the guy dead. 

Dr Jeremy: And 

Val: she sat down feeling sorry for herself. None of her colleagues went to her. She didn't assist the person she shot, she went to prison. At some point, you're going to be accountable for your actions. You will be judged. [00:20:00] They now haven't been afraid to send former law enforcement officers to prison. Whereas before, nobody went to prison. Okay. Now here, we've had, whether it's been in housing, it's been in the NHS, no one has seen bars, so it's probably just a matter of time. 

Dr Jeremy: Yeah. 

Val: It doesn't, there has to be accountability. If you are a manager.

Dr Jeremy: Yeah. 

Val: You knew about this young woman. Alice. You knew she had attempts. You knew the things she used. The family liaised with you. 

Dr Jeremy: Yeah. 

Val: For some unknown reason, it was ignored. Records show poor note keeping, poor risk management, [00:21:00] and no learning from previous incidences.

Dr Jeremy: I'm concerned that her number of previous attempts was a factor in finding this staff member at fault. I can imagine a world where that would encourage people to not record or minimize the severity of things like suicide attempts. If the number of suicide attempts is a factor maybe you record it as self harm or an accident, or you don't record it at all. Because you don't want a record of prior attempts if somebody goes on to kill themselves. 

Val: Yeah.

Dr Jeremy: I could imagine staff becoming risk averse. Not wanting to make a decision. I can imagine people over relying on more restrictive measures to really prevent people from being able to do it. If someone, for example, expressed being suicidal if you think someone's severely at risk, what you really could do, and if you really [00:22:00] think they're going to kill themselves with anything they can get their hands on, the thing you do is you strip them naked in a glass cell. Under 24 hour surveillance, they don't have anything they do that in jails. They don't give them a stitch of anything. Like shoelaces or anything that they could use to Oh, of course. To do anything , they're naked with a glass cell and there's a nurse or a guard watching them. They're under surveillance 24 7. You don't do that to many because it's onerous on the system and it's it's pretty miserable for the person. But I could imagine one of the implications is that more people get treated like that. Not because they are at such risk, but staff don't want to take the chance.

Val: Yeah. 

Dr Jeremy: I can imagine, a workplace culture developing because people are afraid of being blamed for something somebody does, [00:23:00] right? And so I think you're right in the sense that there does need to be accountability, but I'm always thinking about the fact that there are multiple factors that contributed to this person's death. Accountability, one person not taking responsibility is one thing. But think about funding, why are mental health services so stretched? 

Val: No. I'm sticking at this case. 

Dr Jeremy: Yeah. 

Val: Because we can always funding government, not enough staff, not enough that. We already know she was the only one on that ward that had suicidal thought We already know. And they already knew. The attempts and what she always used. There was no attempt. . On their part. 

Dr Jeremy: Yeah. 

Val: To remove the things that she would use. Poor [00:24:00] record keeping, high staff turnover, self harm incidents not reviewed or acted on. Learning from earlier cases not applied. Even after Alice's death, a similar incident happened four months later. These aren't just one off errors. These are structural weaknesses that keep costing lives and it's going to go on and on. And we can always blame funding. 

Dr Jeremy: Well, 

Val: you can always go back to that, but I don't think we should, because it excuse The manager and the trust. What are we going to do? 

Dr Jeremy: No, 

Val: No, 

Dr Jeremy: no. I'm not excusing anyone. There are multiple factors and funding could be one of them. I was very specific when I said, I am not [00:25:00] suggesting that there needn't be any accountability or that this person shouldn't be held accountable. 

Val: My apologies, Dr. Jeremy.

Dr Jeremy: I was very clear about that, but I'm just saying there are many factors involved. We know nothing is straightforward.

Val: But in the doc were two people, the trust and the ward manager. West Streeting wasn't in the doc. 

Dr Jeremy: No,

Val: so the end of the day, we realistically, we know that there's a chain of command, but on the ground the manager and staff, running it day to day should take accountability. That's it. 

Dr Jeremy: Yeah. 

Val: If, 

Dr Jeremy: yeah. 

Val: The reason is funding. I don't see anywhere where the judge said that. No, I don't see it. And I don't think that [00:26:00] even should be mentioned because every department, . Everywhere has a lack of funding. It's always been the case. But as a person that works in the NHS. You do the best you can do. You said someone came up to you, you had a meeting and they said there was suicide you did your job in taking that person to, what was it? The A& E? 

Dr Jeremy: It was in the emergency department. 

Val: You did your part, but then your mind could have said A& E is really Don't do anything. I know what they're like, but you didn't. You did your part and that's what it's about. Everyone's got their part to play 

Dr Jeremy: Yeah 

Val: the manager didn't play his part that's why he was held accountable god forbid, if your patient, the one you took to [00:27:00] A & E went home, dismissed him, went home and something did happen. It wouldn't fall on you because you did your part. You took her down. 

Dr Jeremy: Yeah, I 

Val: think for the most part. Do you see what I'm trying to say? You did what you were supposed to do. Despite what you know about A& E. You still did that. So what I'm trying to say, it's making sense in my head is that everyone has to do their bit and you did yours.

What A& E did is not, you're not responsible for that. For what A& E did or didn't do is not your responsibility. You are only responsible to what you did. Yeah. And that is what I'm trying to say. Everyone has their own responsibility and common [00:28:00] sense tells you what you should do.

This is the right thing to do. You shouldn't need a manual. with an instruction to say, if somebody in your care uses plastic to harm themselves, you should remove it. You shouldn't need everything written down. You shouldn't because you were at home with your child. And your child had a tendency to put plastic bag over their heads.

You would make sure there was no plastic bags in reach of that baby. You would, you shouldn't need a paediatric doctor to tell you that, 

It's hard because it's never a one off. We never learn from the previous death. We just don't seem to [00:29:00] learn. And yes, what has to be addressed throughout the NHS is high turnover of staff.

Why are they leaving? Are the people that work in this sector, well paid? Are they well trained? Do they want to do this job? 

Dr Jeremy: I would add D. What if people are afraid they could be held responsible for someone's death? Even if, this is rare, this almost never happens.

Clearly there were things that should have been done in this case that weren't done. So that's, But if people have the perception that they could be, through no fault or very little fault of their own, they could be held responsible for someone's suicide. Would they want that job? Probably not. 

Val: I'm going to answer your question. You just said before. 

Dr Jeremy: hmmm 

Val: what did you say? Before you went in deep, what was the first thing 

Dr Jeremy: I am not sure what you're asking, 

Val: asked the question 

Dr Jeremy: I was interested in the [00:30:00] unintended consequences of.

This decision. 

Val: Not putting him in jail? 

Dr Jeremy: No finding frontline staff responsible is going to have a ripple effect, right? 

Val: He wasn't just frontline staff. He was the ward manager. 

Dr Jeremy: He was 

Val: That's what he was, 

Dr Jeremy: right? 

Val: Who else are you going to find responsible? The cleaner? He was the manager, the ward manager. Of course, it's gonna be the frontline staff. The people that do the hands on day-today work. 

Dr Jeremy: Yeah, 

Val: his responsibility. If you don't want to be responsible for someone's death, you should have removed the plastic. That might have helped. 

Dr Jeremy: I'm 

Val: sorry, no, you have a file, a notebook I'm allergic to a particular drug, I can't remember the name of it. But my son is able to take that drug. Now, my GP knows. Thanks. [00:31:00] I can't have that. 

Dr Jeremy: Okay. 

Val: How irresponsible would it be for that GP who knows now How I reacted to that drug to give me back that drug. So it's about eliminating that threat. It's we don't know we're allergic to something till we have an allergic reaction. I know I'm going off a bit, but I know what I mean. So it's about eliminating that threat. You wouldn't give a box of matches to a child that likes to set fire to things.

We have to take responsibility and accountability, not just as frontline staff, but as caregivers they have entrusted you to take care of their child. Because their child is not well. She didn't have a physical [00:32:00] illness.

I've got heart disease or a lifelong limiting condition it wasn't about palliative care. 

Dr Jeremy: No. 

Val: Palliative care, they are going to die.

Dr Jeremy: That's the point. 

Val: That's different. 

Dr Jeremy: Yeah. 

Val: But you don't expect this knowing other things have happened. So let's look at that quickly. This name I cannot pronounce. Ruth Simicawitzee. Oh, I can't pronounce it. Age 14. 

Dr Jeremy: Okay. 

Val: Died in 2022 after a fatal self harm in an NHS funded private unit. Jessica Brady, age 27. 20 GP visits. Cancer was missed. Led to Jess's rule for GPs. Oh, I can't pronounce it. [00:33:00] EAM Ford. I do apologize with my pronunciations. Elam Ford Age 16 died after absconding from a mental health ward in 2025. Amy l Choa, age 14. Self-inflicted death in a private hospital funded by the NHS.

These are all cases with the NHS, different ages, backgrounds, but same pattern, preventable deaths that families saw coming, there has to be, a wake up call, as it said before with Alice's one, the record keeping was poor.

That has to change, obviously. High turnover of staff. We know the government has [00:34:00] changed the care work visas? 

Dr Jeremy: Oh 

Val: yes. That's going to impact. They've already done another U turn. More U turns than I do in my car.

Good drivers, as I say, but some might say bad, but one day they're going to have to change that. Might not be today, might not even be tomorrow, but one day they will because we need the workers. Whether in care homes or psychiatric wards, 

Dr Jeremy: we need workers. Supported to do a good job. We need them to stay in their jobs learn. And mentor junior staff. We need the system working smoother, I think, than it is.

Val: Let's end that today.

Dr Jeremy: Okay. 

Val: Do you have any labels or misconceptions? 

Dr Jeremy: Yeah. Obviously the story we've been talking about is the death of this young woman from 10 years ago. [00:35:00] When I think about the issue of suicide. Or, what came up was the distinction between the information we were getting, I was told there was 10 previous suicide attempts and the data you had was 18 instances of self harm. So I think there's a difference in the labelling that it's certainly possible to have a misconception when we're looking at different labels.

A misconception is that, when people self harm, they're trying to kill themselves, not necessarily. And similarly, like I was saying with these patients who they're harming themselves in a way that is severe enough to cause their death. There's some sense in which they maybe don't want to kill themselves. It's possible for people to commit suicide by accident, which [00:36:00] it's confusing. We need to keep in mind there's a variety of motivations involved. 

Val: But aren't patterns predictable?

Dr Jeremy: How do you mean? 

Val: People with mental illness, people may think they're unpredictable. But when you read what Alice did She was predictable. She kept doing it over and over until she succeeded.

Dr Jeremy: Yeah. I wouldn't, I 

Val: wouldn't. So people may have thought. 

Dr Jeremy: Yes, absolutely. 

Val: Happen. 

Dr Jeremy: Yeah. 

Val: If you were 

Dr Jeremy: Assess risk, 

Val: yeah. 

Dr Jeremy: If you want to know the likelihood this person's going to, try to kill themselves.

If they've done it 10 times already, the chances are they're going to try again. So yeah, that was predictable. 

Val: Yeah. 

Dr Jeremy: Yeah. 

Val: It's sad. Some people think families exaggerate, but don't families always know best. 

Dr Jeremy: [00:37:00] Families, are valuable. When you want to assess someone if I'm the psychologist and I'm assessing someone I get a snapshot of them when I do my assessment, but I've, maybe I've met them, it's the first time I've met them, right?

So I'm getting a first impression. It's a snapshot of what they're like. But if I want richer, information, I want to ask people like their friends or their family or their co workers because these are the people who've known them for years, maybe their whole life, so they can provide much richer information.

It doesn't mean that information's infallible, it could be wrong and, families don't see certain things it can add to the assessment and give a richer context to help you understand 

Val: What you don't see.

Dr Jeremy: Yes

Val: they know their child better 

Dr Jeremy: and not just their child, but sometimes people lie, right? If I assess someone and they say, just one or two beers a week. But I talked to their wife and they say no, he drinks a six pack every [00:38:00] night.

That's a much different picture 

Val: we're going to end with this close. 

Dr Jeremy: Okay. 

Val: So we, we know that NHS is there to protect us from the worst moments of our lives. But what happens when families see danger? Speak up and the system still doesn't listen. Alice's story reminds us that safety isn't just about policies. It's about culture, compassion and accountability.

And until every warning is taken seriously, every past mistake is learned from, and every patient is treated as a life worth fighting for, we will keep repeating tragedies. That should never have happened. The question is how many more lessons does the system need before it [00:39:00] changes? Okay. And I think we should give out the number for the Samaritans.

They are available 24 7 on 1 1 6 1 2 3. And there's organizations like Inquest who support families navigating preventable deaths and accountability. Thank you for listening. 

Dr Jeremy: Thank you Val, said there. 

Val: We'll see you next week. So it's bye from me Val Barrett. And 

Dr Jeremy: I'm Dr. Jeremy Anderson.

Val: Thank you Dr. Jeremy. Goodbye. 

Dr Jeremy: Thanks Val, bye bye. 

Val: You 

Dr Jeremy: did record, right?