Probably you haven't heard of Chris Blagbrough. I hadn't either until this afternoon when I stumbled across his story whilst carrying out a Google search on another topic.
I stopped and read about Chris. I hope you too will spend a few minutes finding out about him.
Chris died in 2001, almost seven years ago, but the story of his last three years leading up to his suicide is another condemnation of mental health provision in the UK.
An outline of his life is appended below (from The Yorkshire Post)
A 'Nightmare of Care' for Patient Who Died at 10th Suicide Attempt
Peter and Jeanette Blagbrough said they believed their son, Christopher, 22, was driven to kill himself after being forced to endure a "living nightmare" while a patient at St Luke's Hospital, Huddersfield.
Mr Blagbrough was found hanging from a window at the hospital's Castle Hill Unit, where he was being treated for mental illness after he launched a knife attack on his father.
Health bosses have since apologised to Mr and Mrs Blagbrough for the hospital's failings, which were uncovered in an inquiry carried out by Calderdale and Huddersfield NHS Trust in the wake of the tragedy.
Three nursing staff have been disciplined and sacked for not following procedures on the night Christopher Blagbrough died.
Last night his father branded the hospital "a disgrace", and said he and his wife had received no written apology from the trust. "We don't feel as though we have got any closure, and we don't feel the hospital has done anything to admit to us they were in the wrong," he said. "We have never had a written apology, but we don't want one now." Mr Blagbrough, an apprentice engineer, began suffering from stress when his father had a near-fatal brain haemorrhage, leaving him unable to work. He took on the extra responsibility of winding up his father's company and developed a severe vitamin B12 deficiency, which led to depression and psychosis.
In December 1998, he attacked his father with a carving knife, stabbing him twice in the back, causing minor injuries. Mr Blagbrough recalled: "When Chris came at me, his eyes were wild, and I had to restrain him. But it wasn't him. He was deathly white and didn't know what he was doing. I rang for an ambulance, and by the time it came the strange look had gone.
"He was very agitated about going to jail, but I told him I was going to make sure he got the help he needed." Despite his father's insistence that he did not wish to press charges, Christopher Blagbrough was charged with attempted murder and sent to Doncaster Young Offenders' Institution.
"We were told by the police that they were charging him with the most serious offence they could in order to ensure Chris got the best possible care. In the end, that led to his death." His son appeared before Bradford Crown Court in January 2000, where he admitted unlawful wounding and was detained under the Mental Health Act at St Luke's Hospital. But his father was so concerned about his son's treatment in the unit that he absconded to Spain with him. When the pair returned a month later, Mr Blagbrough was banned from seeing his son and had not done so for eight months when the latter took his life in October 2001.
"We had been complaining about his care for months, and when we got back from Spain, the hospital wrote to me and said if Chris returned to the unit, they would look at our complaints in a different light.
"I thought they would review his detention, but the first thing they did was ban me from seeing him. In the eight months before his death I never saw him."
The inquiry found staff panicked when they discovered Mr Blagbrough's death, and failed to inform his parents of the incident for more than four hours.
Three years on, the Blagbroughs have finally achieved their aim for a jury inquest to be held into their son's death, and contributed £8,500 towards legal costs. West Yorkshire coroner Roger Whittaker said: "The jury were directed they could bring in a narrative finding. The jury concluded Christopher took his own life while the balance of his mind was disturbed. They also expressed the view that his death could have been prevented."
Mr Blagbrough's parents are still trying to come to terms with their loss. They said they hoped the inquiry's recommendations would be implemented in full, to prevent a similar tragedy from happening again. [firstname.lastname@example.org]
Trust Says Sorry for Catalogue of Failings
A catalogueof failings in the standard of mental health care at St Luke's Hospital were exposed following an inquiry into Christopher Blagbrough's suicide.
A panel of experts appointed by Calderdale and Kirklees NHS Trust concluded that health professionals at the hospital had struggled to diagnose Mr Blagbrough's condition, that care had been inappropriate and the overall risk assessment and management of it was inadequate.
The panel said he ought to have been placed in a medium-secure unit for a comprehensive risk assessment, and the observation policy was not sufficiently implemented.
Staff failed to ensure his safety and panicked when they discovered him hanging. It was more than four hours before his parents were informed of his death, the inquiry found.
But the seriousness of the offence which led to his arrest could not be minimised, given all the circumstances, and difficulties in resolving large numbers of complaints contributed to the paralysis of the clinical care for Mr Blagbrough.
Recommendations made by the panel included better staff training; collating information about untoward incidents to identify trends; ligature scissors to be available on all psychiatric wards; and improvements to psychological and occupational therapy.
Calderdale and Huddersfield NHS Trust and South West Yorkshire Mental Health NHS Trust apologised for the failings and issued a joint statement. Judith Young, chief executive of South West Yorkshire Mental Health NHS Trust, said: "We offer our sincere sympathies to the family of the patient who tragically died, and apologise unreservedly for the failings that have been identified. "Sadly, we cannot change the tragic events, but we can learn from them, and we have made many changes. Much progress has been made in the past three years. All the actions recommended by an external inquiry have been implemented, and improvements made to the physical environment of the unit.
"We have a comprehensive training process for all staff, as well as a structured training programme to support staff as they undertake their duties."
Chris' parents write a much fuller version of his life and the terrible failings in his care. It is very much worth taking the time to read their story. Be prepared to get very angry.
For once I make no criticisms of his care: the stories here do that well but at some point we must start to learn the lessons from the unnecessary and wasteful deaths of people like Chris Blagbrough.
How many more must die?