Extra steps taken to try to prevent missed opportunities after death of agony aunt

Daily Mail advice columnist Ms Brampton walked into the sea near her St Leonards home in May after Sussex Partnership NHS Foundation Trust missed two chances to intervene in her care.

A spokeswoman for the trust told The Argus yesterday that following her death they had made changes to the way referrals are recorded and apologised for "areas where our systems should have been better".

A referral from Ms Brampton's GP stating that she was "in crisis" and having "strong suicidal thoughts" was not followed up by mental health services in March, an inquest heard into her death on Tuesday.

When she was referred again in April the team did not consider her a high enough risk.

Now the trust has made changes to make sure "all cases and referrals, no matter how informal, are recorded on an electronic system".

Having suffered from bi-polar depression for 15 years, Ms Brampton had previously voiced concerns about NHS mental health services.

Her friend Emma Ridout told her inquest: "She didn’t have any confidence in the NHS helping her."

Her private psychiatrist Dr Adrian Lord said she had "painted a very jaundiced view " of her local mental health services.

Ms Brampton's family raised concerns that referrals could be wiped off whiteboards by mistake - leading to the trust looking into switching over to electronic systems.

Her death was one of thousands of suicides committed by patients under the care of mental health services across the country.

The number has been growing in recent years but that is largely down to the rise in the number of people seeking help.

Sussex Partnership is currently treating 63,000 patients and between April 2012 and September 2016 177 took their own lives.

The trust said in a statement: "Suicide is devastating for the families concerned. We do everything possible to prevent this, working in partnership with other health and social care organisations. We always do our very best provide people with the right support when they need it, both when they’re in crisis, in hospital and to try and keep people well and at home wherever possible. "

Speaking about Ms Brampton's case, the spokeswoman added: "In this instance our team agreed with the GP to call the patient rather than open a full referral.

"This was not carried over in the diary nor handed over because of unplanned staff absence. Now all referrals, even those not fully being opened are recorded on the electronic patient system and on the assessment board.

"As a routine every member of staff routinely checks the assessment board and the electronic patient system. The electronic system is also used in the handover process.

"In triage meetings, as a direct result of this case, staff record triage decisions straight onto the electronic patient system rather than writing notes up afterwards. This means information is recorded accurately there and then. Other areas to look at following this case include a single point of access for all referrals. As a trust we are looking at how this could be introduced across the organisation. "

COUNTY HAS ONE OF COUNTRY’S HIGHEST SUICIDE RATES

SALLY Brampton was not alone in suffering from depression.

It is a condition that affects thousands of people in Sussex – but many struggle to shake off the “damn fog” as she called it .

As an agony aunt she helped thousands of people with their problems but was unable to help herself with her own – all too common an effect of mental illness.

Sussex Partnership NHS Trust is currently treating 63,000 patients and between April 2012 and September 2016 a total of 177 of them took their own lives.

In 2015 and 2016 the total was 36.

Sussex has a suicide rate of 10.9 per 100,000 – higher than the national average and among the highest in the country – making it a problem that affects us more than many.

And Brighton and Hove does have the highest rate in the county with 12.9 deaths per 100,000 residents.

Sussex Partnerships NHS Trust’s area also has some of the highest numbers of hospital admissions for self harm.

With more and more people recognising mental health problems, the system is struggling to cope with its highest-ever numbers of patients.

Funding is allocated as a “block contract”, receiving a fixed amount of money regardless of the numbers of patients, but the trust has insisted services were not overstretched and it was “working extremely hard to deliver the very best care to all of our patients every day”.

Sadly cases like Ms Brampton’s, where human error causes mistakes with the most devastating consequences, are all too common.

The most recent inspections by the Care Quality Commission said the trust needs to make improvements.

In 2010 Sussex Police launched an investigation of corporate manslaughter into five deaths at the trust’s hospitals, including two at the Woodlands Centre in St Leonards, which was temporarily closed.

However, no criminal charges were brought as a result of the deaths and an independent investigation into Woodlands gave it the all-clear.

Mental health bosses apologised to Susannah Anley’s widower after she was able to take her life at the unit despite several suicide attempts. In a letter written to Mrs Anley’s husband Mark, the trust said it was willing to accept “full liability” for what happened.

But the letters of apology and promises of lessons learned have become all too familiar.

Following Ms Brampton’s death it apologised again yesterday – and once again promised change.

A spokesman said: “We would like to offer our sincere condolences to Sally Brampton’s family and friends. This case has highlighted some areas where our systems should have been better. The team concerned has changed these systems to make sure referrals, however informal, are always followed up. Across the organisation we continue to work closely with all our partners to make sure where they have concerns about a person’s mental health they know how and when to refer it to us and can be confident it will be followed up.”

No doubt the trust has an uphill battle struggling to keep alive those determined to die.

But in July this year another investigation was launched after the death of a patient on the Willow ward at Hellingly Hospital, near Eastbourne.

In addition to suicides, the trust has also come under fire for even more violent killings involving those supposedly in their care.

It launched an investigation into 10 homicides linked to its patients following the conviction of schizophrenic Matthew Daley for the death of grandfather Don Lock.

A spokeswoman for the trust said yesterday: “Suicide is devastating for the families concerned. We do everything possible to prevent this, working in partnership with other health and social care organisations. We always do our very best to provide people with the right support when they need it, both when they’re in crisis, in hospital and to try and keep people well and at home wherever possible.

“You cannot completely eliminate the chance of human error. That’s why we have to put in place as many safety nets and checks as we can, using a mix of experienced, highly-trained staff and electronic systems and technologies to support them.

“We have a suicide prevention strategy which is about making all our communities ‘suicide-safer’, that is working hard within our services but also with partners and members of the community to make sure we, as a community, are pulling together to reduce the risk of suicide.

“The strategy looks at how we train staff on risk assessment and care planning, how we work with high risk groups, how we work with staff after a suicide has happened and how we continue to develop a culture of openness and transparency so that we can learn if a suicide happens.”

YOU’RE NOT ALONE, SO REACH OUT FOR ADVICE

Former chief executive of Sussex Partnership NHS Trust LISA RODRIGUES, who has herself suffered from mental health problems and now works with a suicide prevention charity, wrote the following blog about Sally Brampton, a journalist she greatly admired.

I WAS saddened to hear of Sally Brampton’s untimely death after a long battle with depression. She was 60, the same age as me. From my own experiences of depression, I know a little of how things must have been for her. My heart goes out to all who loved her. May she rest in peace.

For those who are struggling, I say this. Mental illnesses mess with your head. They make you believe bad things about yourself. That there is nothing wrong with you other than laziness, moral cowardice, being hateful and lacking what it takes to lead a normal life. That you are not worthy of help. And that you must face this awful, isolating thing alone.

But struggling on alone is not a good idea. Nor is pretending to be OK when you are not. I know this from my own past, effective but wrong-headed attempts to keep how I was feeling to myself. In the end, keeping secrets just causes more damage. It can be really bad for you and those you care about.

If you are overwhelmed by negative or frightening thoughts, if life feels grim or even just pointless, please, please ask for help.

Talk to a friend or someone else that you trust.

Make an appointment to see your GP.

Check out the Grassroots Suicide Prevention StayAlive app – available free to download to iPhones and Androids.

Phone Samaritans on 116 123 or one of the other helplines.

If you don’t know what to say at first, or feel embarrassed or tongue-tied, it doesn’t matter. If you are afraid that the words won’t come, try writing it down.

Social media has been a massive help to me. I have made friends online who always seem to be there. They have been to those evil places. Not the same as mine, because we are all different, but their own terrifying versions. They know how lonely it feels.

Contrary to what you may hear, there are wonderful services available and treatments – medicines, many different sorts of therapy and other practical techniques – that work for most people. It can take time to find the right ones, of course. And it will take a lot of courage and effort on your part. There are no miracle cures. But I promise you, seeking help really is worth it.

Believe me, you are not alone.