I thought the idea of medical involvement was to help people with serious mental disorder manage their lives as well as possible. They can’t control the person in all respects.
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Interesting question…
I have practiced mental health law for more than a decade and I have had clients recount to me how appalling community provision is.
I will put my hands up and say that I took some of what was said with a pinch of salt because I didn’t believe how bad they said it was.
I have a very close friend who suffers from treatment resistant depression and whose private medical insurance has washed its hands of him. He is accordingly left in the hands of our local NHS mental health trust.
I can honestly say, I am truly shocked at how terrible the provision is for someone who is both high risk, but also high functioning. The service just doesn’t recognise his needs because he isn’t drunk on a corner or sectioned in a ward.
I have gone to appointments with him when someone has introduced themselves as “the duty clinician”, has sat down at their desk (in gym attire), having first done limbering up exercises, and then failed to recognise the high risk person sitting in front of them.
The various people he has seen try to gas light him, denying what he recounts to them has happened with their fellow clinicians, only for me to confirm that what he is saying is actually true.
I have moved him into my house because he is so high risk, yet the constant stream of random occupational therapists, care assistants and other entirely unqualified people dealing with such a high risk individual fail to recognise how close he is to killing himself.
On the odd occasion that we have managed to sit in front of an actual psychiatrist, there is some recognition that he is very unwell and a care plan is put in place, but is never followed through by the randoms within the service.
I am not sure who should be held responsible for someone completing suicide when so many opportunities have been missed. If it isn’t the psychiatrist, then the psychiatrist responsible for the service needs to make changes.
I debated whether to name the service, and typed this into my notes on my phone so I could decide whether to name West London NHS Trust MINT Team as such a negligent service provider, but re-read and checked what I have typed a number of times, and have assured myself that what I have said is accurate and true.
Patients deserve better and if they can’t get it then the buck has to stop somewhere.
When the inquest happens, even though I desperately hope it doesn’t, I will fight to give evidence as to the appalling care given by the Ealing MINT team and its responsible clinicians - they are paid to be responsible, yet pass responsibility to entirely unqualified and inexperienced people.
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The title of the OP is “Why are mental health professionals and doctors held in some way responsible for a person’s suicide soon after contact?” just to keep it in focus.
Andrew:
I thought the idea of medical involvement was to help people with serious mental disorder manage their lives as well as possible.
I thought and think so too, partially. My take will be expected to differ to 95% of all people, so I expect a hiding.
Medical involvement - if one conceptualises that as doctoring - is about what qualified doctors will do (or not). I am unable to deal with every variation of the word ‘medical involvement’. In this new alternate universe I am trapped in, ‘medical’ could mean ‘anybody’. Similarly ‘mental health professionals’ could be anybody who went on a ‘course’.
I’ll stick with medical doctors - who are properly qualified, which normally means a psychiatrist. I cannot deal with each and every ‘mental health professional’.
Psychiatrists aim to treat diagnosed mental disorders [DMD] but not everybody will agree with that. But for those who agree, treating a DMD is not easy and that’s because there has been, in my opinion and experience, a widespread failure of proper diagnostics in psychiatry over the last 20 years. [Note that I said ‘diagnostics’].
I like to flip psychiatric situations into physical health analogies because that was where ‘doctoring’ originally started. So by analogy what happens repeatedly in psychiatry is this, “Belly pain.. ah have this pill or perhaps you need an operation to open your belly and we can take out your appendix, or if its your womb we take that out as needed. Oh but wait it could be a small bowel problem, so we could just chop out some of your small intestines. Oh but then again it could be your large bowel, so we might have to take that out too. Do you consent? Sure you do.”
Or “It could be COPD or a heart attack.. let’s stop all your medications and see what happens - that’ll help us diagnose you better.”
Shoot me down - or stop me now - but my opinion is that psychiatry has become an unregulated pseudo-science claiming to be an ‘art in medical practice’, so as to continue its hocus pocus.
I’ve seen shambolic suicide assessments and it is rare to find even a proper mental state examination (MSE). In fact most people, even some trainees, don’t know or care what a MSE is anymore.
Unbeknownst to most health professionals and psychiatrists they are caught in the net of ‘operational duties to protect life (Article 2)’. But some will argue that, ‘It’s nothing to do with me - that’s about the organisation’.
But if one does not like Human Rights because it’s soon to be abolished, then there are still a raft of duties of care arising from the General Medical Councils standards that pertain to assessments, patient safety and appropriate treatment.
Where there are standards there has to be accountability and from that flows responsibilities.
The statistics show that there is some statistically increased risk of suicide for depressed persons coming into contact with psychiatrists and ‘mental health professionals.’ This means - do your jobs properly!
About 50% of outpatients will not disclose suicidal ideas or intent. You don’t need to be a psychiatrist to realise that non-disclosure will be worse among inpatients. So when I see ‘No suicidal ideas or intent expressed’ in records, I know that’s a fudge. Such records usually have little substance of how suicidal ideas and intent were explored. But wait - the way it works for inpatients is like, ‘We can’t put people on obs for what they don’t say - least restrictive please - the CQC will come down on us - Commissioners will be fumin’ - patient expressed no suicidal ideas, drop those obs now!’ - and they bend to the pressure which is said to be ‘no pressure’. In fact the official line is that ‘anybody who needs obs will get it’. Really?
But psychiatrists are not fully to blame - though I would apportion 65% of blame/responsibility when things go wrong. How dare I? I dare and I do.
Systems surrounding psychiatry have been pushing for speed of assessments, without quality assurance especially post-COVID. What systems want is production line assessments with roughly 10 to 20 min patient contact., followed by rushed documentation and poor liaison. Really? Yes - I know having worked in both general psychiatry and learning disabilities (in addition to forensic psychiatry). I see systemic pressures forcing the most weak-willed of psychiatrists to cut corners in order to serve their masters. What - do I have time to do audits on this? I do not.
When you are invested in a home, kids’ schools and partner’s job in a particular location, you rock no boats and you do not leave the job. You hold on cuz hols in the sun, food on the table and family stability mean everything. But if you’re like me who could not care a flying flamingo about any of that, you say ‘Goodbye - I’m not doing your dirty work and I don’t want your dirty money - next job where I can make a difference for patients. Blood will not be on my hands.’
If one doesn’t like the above, well then ‘one’ is probably not the type to like reading Coroner’s PFDs either.
So to round off what will no doubt be labelled and ignored as a diatribe, I say “Hunt them down, and hold them to account when anybody commits suicide after recent contact.” Should I soften my words? I will not! When I see any patient who is depressed or potentially suicidal I give them all the time in the world they need. I couldn’t care less about clinic schedules, CPAs and Tribunal reports pilled up, and upsetting my masters. I document, liaise and document again with timestamps. That makes me labelled as OCD or OCP apparently. Do I care what’s my label? I do not. The only thing that matters is the life in front of me.
Now give it to me - for just satisfaction.
Firstly medical involvement is limited to diagnosis and prognosis. It does not for instance solve debt problems, relationship issues, lack of funds or accommodation. Medication is at best in my opinion limited to 20% in improving a patient ‘s quality of life.
Next suicide is not a mental disorder. Just what is treatment for suicide? Incarceration to a psychiatric ward is temporary relief. (Rabone v Pennine Care NHS Trust). There is a duty owed to patients by merely stepping on a NHS site as there is on entering a local authority building and requesting assistance.
When a patient dies, the issue of accountability occurs (perhaps for negligence and compensation?) if known to medical services. Just want is the state meant to do with limited resources?
The issue of euthanasia is interesting if a person really wants to end their life…Does one continue to provide services incases which are untreatable?
In responding to Kyle, I take the words on the page as is. I do not know meanings other than the words, or what may have been ‘meant’. If you want a juicy story first, flip to the end of this post now.
[quote=“kyle5, post:4, topic:4478”]
Firstly medical involvement is limited to diagnosis and prognosis.
If I say this is incorrect, I will appear to be pulling rank when I intend no such thing. After 30-odd years in psychiatry, I have come to realise that most average citizens in the UK and even some ‘mental health professionals’ are unaware of what exactly psychiatry is. An informal poll of people in services reveals that 99.9% of individuals do not know where or when or how the term ‘psychiatry’ emerged, nor are they aware of what ‘psychiatrists of today’ do. In legal circles a substantial proportion of people think I do ‘counselling’ or ‘injecting’. I have been limited in my ability provide references to ‘What is Psychiatry’, and I am unable to give a dissertation here.
In the fast-paced attention economy built by meteoric expansion of social media, psychiatry will remain misperceived for the next three decades in my estimation. So - no - medical involvement by psychiatrists and non-psychiatrists is not limited to ‘diagnosis and prognosis’ which then brings up debates about ‘medical model’ when the world moved on to the biopsychosocial model over 20 years ago.
Nor do philosophers or social workers solve medical problems or aviation problems.
Back in 1990 when I was a fledgling, I was told by a senior psychiatrist “Philosophy is a useless discipline in psychiatry because it does not provide solutions for the work we do”. Fast forward a couple decades the RCPsych took an interest in philosophy a ‘discipline’ that provides no solutions.
In the new social media world, everybody is entitled to express their opinion and receive respect for expressing their opinions. Whether those opinions have a foundation based on underlying evidence a non-issue.
Next - homicide, anxiety, low mood, hallucinations, obsessions - are not mental disorders. I of course run the risk of being sent to the GMC for such a statement, and I take that risk squarely. I’m not going to explain my statement here. I’ll save for when the authorities come for me.
No psychiatrist can treat suicide or what is not a mental disorder - anymore than a social worker can treat back problems.
Psychiatrists who unswervingly embrace holistic care in a biopsychosocial model make contributions to reducing suicide risk by treating and ‘managing’ mental disorders in multidisciplinary teams (that they have no control over). There is only one such psychiatrist known to me in the whole of the UK. I’m not at liberty to say who that is. Sorry.
‘Incarceration’ is wonderful social media language that often conjures images of people in chains on grimy floors, among minds who don’t know what the insides of a modern psychiatric hospitals looks like. Scientologists would love such terminology. [I am not saying that you are attempting to conjure anything or that you are a Scientologist. The issue is the ‘power of language’.]
The reality is that only a minority of patients are ‘incarcerated’ (aka detained according to law) for assessment or treatment purposes. They’re not in chains, strapped to chairs, wearing leather harnesses and having their brains fried with electricity, as certain antipsychiatry groups would have the public believe. I’ve never seen it - missed all that over the last 35 years of UK psychiatry.
In reality with the introduction of the ‘least restrictive principle’ which is not law, it’s almost a ‘free for all’: patients in large majority can buy whatever they like; stuff themselves with junk food and takeaways; become morbidly obese and blame their pills/injections; surf the internet to distribute video of other people committing atrocities or committing suicide; get up to unseen extremist activity (undiscoverable); enjoy the comforts of well-furnished and heated rooms (and hoard junk in them if they like); gain little or no insight or knowledge of their mental disorders; cause psychiatrists (Responsible Clinicians) to be bullied to give them generous S17 leave without conspicuous rehab objectives or robust risk control plans; further their killing addictions that will deposit circa £2000 per year to ‘the State’ for the pleasure of killing themselves (if it’s legal it’s fine!). So the so-called ‘incarceration’ is not all in ‘dungeons of despair’.
Mental health and certain other authorities have a positive obligation to take reasonable steps to protect the lives of patients when they know or ought to know of a “real and immediate” risk to their life.
This seemed to take off from ‘The Osman Test’ in Osman v United Kingdom (1998) [coincidentally same year as the HRA 1998 - nothing inferred], then expanded by Savage v South Essex Partnership NHS Foundation Trust (2007 to 2009) for patients in mental health services, then Rabone v Pennine Care NHS Trust (2012), then Morahan v West London Assistant Coroner (2021) refined the application of Article 2 to healthcare settings, and then parking somewhere with Maguire (2023). But not to worry - as many know and expect - Human Rights is to be torn up in the UK as we are taken out of the ECHR (nothing to do with Brexit) and then out of the UNCHR. So, in the absence of a written UK Constitution (compared to the USA) the next 10 years are expected to really ‘fruitful’. [I’m not into a debate on ‘written or unwritten’ Constitutions please.]
To give a fully contextualised answer will require about 5000 words which nobody will read, and will take me into lessons forgotten in Nazi Psychiatry. [Caution: I am NOT saying there is Naziism in UK psychiatry or mental health services!]
Compensation? Think about CNST - that ‘wonderful’ piggy bank that holds over £50 billion - and funded by His Majesty’s Treasury. Unbeknownst to most, it pays out and nobody will be allowed to find out is my bet, how much is paid out to cover what would ‘negligence’ in mental health services, if such cases reached the ‘steps of the court’. If you’re not an ‘ambulance chasing lawyer’ you are not in the money!
I’ll purposely avoid exploration of ‘euthanasia’ as it goes down endless rabbit holes as the so-called ‘Assisted Dying Bill’ is upon us.
But your question on services for the untreatable [mentally disordered I presume] is a good one. While the HRA 1998 and ECHR still have some force, my short answer is ‘yes’.
My longer answer condensed from 8000 words is: In my estimation nobody actually knows if the ‘untreatable’ are truly untreatable. All I know is that I meet on occasions the seemingly ‘untreatable’ and they are not untreatable. Case in point (no rich details): two patients who were clearly on evidence ‘treatment resistant schizophrenia’ - those diagnoses wiped away without clear and rational reasons - and then the fashionable EUPD substituted (without satisfying to ICD-10/11 diagnostic criteria.) Result? The two drugged up for the next few years (as if CG78 didn’t exist) expanded their criminal careers in hospital, etched deeper dysfunctional pattern of behaviour which then re-confirmed EUPD. So who am I to come after a line of 7 previous RCs and say 'nonsense!'? Think S127.
Solution: keep them locked up (aka ‘incarcerated’, detained or whatever under a guise of ‘untreatable’). NHS England is not gonna know what’s what. If one is a member of the general public you can have no knowledge of such cases caused by gross systemic failures and failures of psychiatry. Instead, you may hold your chin, tilt your head and wonder, “Who does this guy think he is? Is he a fake psychiatrist? He sounds more like a journalist. Surely, he must know that the CQC would have found that sort of stuff and dealt with it.”
And now - yes he goes on forever - I give you another scenario. In-patient biological female around early 20s, with the classic rash of EUPD that has unfolded nationally post-COVID - detained under S3. Left the unit on unescorted leave (that I inherited), walked 0.5 mile to the top of a roundabout above a busy motorway. Members of the public called police as it was obvious she was moving to some position to make a jump onto the motorway below. Police response was swift. She was taken away - and back to the hospital. I considered the risks and her mental state after careful examination. I applied 27.10 of the MHACOP and came to a preliminary view that her unescorted leave must stop. Result? If you know the insides of ‘mental health services’ you would expect what happened next: UPROAR! ‘People’ fiercely opposed on grounds that that would make her worse, that she would then kick off, up the ante with self-harm and suicide attempts on the unit. I’m told “She does this about twice a year; we know about it! It’s nothing new. It has happened several times before. She never jumped.” I did what I had to do, according to law and sound medical practice. But wait - it didn’t stop there. I was hounded out by a barrage of complaints about similar decisions in related circumstances, over the next two weeks. [Of course, I’m not told the substance or particulars of the complaints. You don’t understand how it works in certain health services.]
Obviously - as I said before, I don’t set myself up to carry blood on my hands. Solution? Leave them - yes leave the job and let them find a better RC than me. Hence, I am usually ‘Guilty by Reason of Sanity.’ But here’s the kicker - when I leave dodgy units swiftly - there is usually a fiasco that follows by a time lag of about 3 years. How would I know? It’s happened 3 times already. I am not a paid change agent. I am nobody and nobody really wants to know what I see or know, other than the usual lip service of brief informal conversation.
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I enjoyed reading the dissection of my initial response. As much as I would like to respond with a 5K worded response. Instead I am going to suggest to readers to consider reading: ‘ The Sleep Room,’ by Jon Stock (2025). Obviously there is a an abundance of information on psychiatry and I for one would not criticise the profession, which I hold in esteem.
Terrible! 
I know exactly what you mean. I had a learning experience about the appearance of high functioning, when last year I saw a marathon runner who was complaining of depressive symptoms and feeling suicidal; whilst they were still running on average 5 miles plus per day. A very experienced senior nurse told me about a different sort of syndrome with marathon runners. I checked the research which confirmed this. The individual was well presented and you would not imagine they were clinically depressed. But I was armed with knowledge and my ICD-11 depressive episode checker. Caution: I don’t use these things on a tick box way. I asked mainly open questions and made not leading statements to facilitate interview and exploration of MSE. It was shocking and a sound learning experience that the patient turned out to be moderately severely clinically depressed with suicidal ideas but had several protective factors. [Caution: protective factors are not a shield against suicide, in the way I see ‘some professionals’ using them. I mean it’s great - isn’t it - if there are a few protective factors, well golly gee you’ve saved a ton of work and a bed. What about the patient? Some are unaware that the patient has become incidental in many services. The spreadsheet is the greater priority - which nobody will admit. Tough - actions speak louder than words.]
Seen it all before. Everybody is an expert these days in assessing ‘mental health’ and suicide risk. The system believes you can put bums on seats lecture them on what to ask or look for, and that’s it - Bob’s your uncle - we have a suicide risk assessor!
No surprises there for me, either.
I know. I’m sure. The health care organisation is primarily responsible. Quote me.
In the privacy of my apartment that statement caused me to burst out laughing, which does not mean I am laughing on this forum.
‘People’ seem to think that ‘the psychiatrist responsible for the service’ is somebody of importance and power. Think it through: who exactly is that person/psychiatrist. You assume it’s a psychiatrist. The world changed. Gone are the days when you could expect a ‘Clinical Director’ who is a psychiatrist to be in charge. Today It could be anybody. And as I write this I reminisce on lead psychologist who was in charge, and their coterie of other psychologists caused havoc in a Trust up north somewhere. It took the Trust over 5 years to sort out the coterie’s misguidedness.
But then - from my experience - medical (psychiatrist) clinical directors are pretty powerless. I won’t go back into my long definition of what ‘power’ means. In essence it is about the ability to influence timely change. Then their are 'Clinical Leads. These psychiatrists have absolutely not power to change anything. How would I know? I’ve met many of them and they told me exactly that.
And then you consider a raft of other positions like Associate Medical Director (which goes by various titles these days). They move in the slipstream of the Medical Director and basically they have to obey.
Nobody is willing to talk about Medical Directors because they have national connections. These are really powerful people who are involved in high level decisions involving spreadsheets. It’s rare to see them at ground zero, talking to consultants. Why would they want to do that? Well if you’re member of the general public you might say, “Because they want to improve services obviously!” Oh Blimey! I didn’t know that obviously. And that’s where I stop.
You’re obviously not a doctor, or if you are, you like rods going into your own back.
I couldn’t agree more. I know exactly where the buck stops. But freedom expression is limited on on this forum. I’m on a short leash, so I say nothing more.
Yes - you will give that evidence either to a Coroner or some other investigatory body. Your evidence will join a chorus of thousands of similar words. Your words will be in reports stacked high and shelved. The Coroner may issue a PFD which is toothless because nobody is legally obliged to respond to a PFD (as is seen by long and growing list of non-responders in the public domain). Lessons will not be learned and there is ample evidence for that in the last 5 years at least. This means that lessons are meant to be forgotten and mistakes repeated. If I can’t explain that further it’s because my freedom of expression is limited, not by law.
Come on - I’m not defending ‘certain Responsible Clinicians’ at all - the point is that they tend to have no choice but to delegate responsibility to underqualified people attracted by meagre wages and desperate to climb ‘the ladder’. Everybody has to eat!
Who’s responsible for that state of affairs (not specific to any one Trust)? Ahhhh…that’s the stuff we can’t talk about on this forum.