Issue 40 - VIEW magazine

In memory of those who have died

Ifirst heard the phrase , ‘lives of quiet desperation’, when a critic was tr ying to capture the appeal of the US shor t stor y writer Raymond Car ver

I thought of it again when I was first approached by Contact’s chief executive Fergus Cumiskey He asked me would I think about bringing out a themed edition of VIEW which would look at the issue of suicide

And think about it I did

My initial feeling was to say no to Fergus The subject is difficult, and also, would anyone want to read a 32-page magazine which exclusively concentrated on suicide?

But I’ve never wanted VIEW to shy away from issues that matter And the deaths of so many men, women and teenagers do matter. Those who have taken their own lives may no longer be around but the stories of who they were live on in the lives of those who loved them

I finally said yes to Fergus. And if you ’ re reading this then I hope you will read the other stories and comment ar ticles in the 40th edition of VIEW.

I’d be telling lies if I said it was easy to

By Brian Pelan Co-founder, VIEWdigital

put together. It was hard.

My first morning on the magazine was spent watching a BBC documentar y about a young woman whose husband took his own life In an effor t to tr y and understand the reasons behind it and to attempt to answer some of her own questions, she travelled the length and breadth of Britain to talk to families and individuals who also lost loved ones

I felt ver y emotional as I watched and listened to the trauma and anger of people affected by suicide It was as if they had all become par t of an exclusive club which none of them wanted to belong to

I would like to thank all those who assisted in the production of this magazine

I also feel privileged and humbled to play a par t in it. We all must raise our voices to demand that the issue of suicide prevention be put at the hear t of Stormont’s Programme for Government.

The reasons why people take their own lives may be complex but we owe it to them to adopt measures which tr y and effectively address it To ignore it is wrong. To adopt economic measures and policies which may exacerbate desperation in people’s lives is also wrong

The piling on of student debt on our young, and incarcerating people with mental health problems in our jails, is not the answer and never can be the answer

We have a choice: either we tip-toe around the issue of suicide and apply sticking plaster solutions or we lobby for an effective strateg y which is aimed at easing the plight of those who are leading lives of quiet desperation

By guest editor Fergus Cumiskey Chief Executive Contact

The World Health Organisation declared in 2014 that suicide is preventable At Contact we encourage the fast expanding worldwide Zero Suicide movement with the conviction that all suicides are preventable until the last moment of life

How then might we protect our families and friends from suicide as a preventable catastrophe? How do we live with the fact that 318 local families lost a loved one to suicide last year alone? How to make sense of the reality that suicide kills more people globally than all wars combined? How do we invest in hope when more people have died here by suicide since the Good Friday Agreement than were killed during the troubles?

Such are the challenges faced by ever y family, ever y community bereaved by suicide , united in grief, struggling with the isolation of stigma and traumatic loss These questions are stretching politicians, health and justice system leaders ever ywhere We need courageous, audacious urgent understanding driving disciplined innovative leadership to wage war on suicide as the public health crisis of our times

The UK decriminalised suicide in 1961 More than 50 years on we have yet to draft legislation to guarantee suicide prevention education for doctors, nurses, social workers, counsellors and teachers

Could you imagine airplane pilots on take-off or touch-down without access to decades of distilled learning from Black Box plane-crash analysis? Pessimistic attitudes prevail across health and justice systems that mental ill-health mor tality is inevitable and suicide is the means We must challenge this deep, silencing, self-fulfilling prejudice .

Suicide rates in Nor thern Ireland have increased by 20 percent since 2005 yet have decreased by 10 percent in Scotland.

So why this par ticular Celtic disparity? Many rightly point to the severity of our conflict legacy Social isolation, perceived burdensomeness, thwar ted belonging, relative inequality, entrapment and pover ty

are also devastating suicide risk factors

When safety-focussed industries identify causal factors for preventable death, they act fast to change the culture , change the process and change the outcome . Major safety initiatives in the aviation and road traffic industries, spearheaded by legislative change and education, resulted in 80 percent death rate reductions over the past 40 years

How are we getting it so wrong when suicide seems imper vious to 10 years of prevention effor ts? Is it possible we star ted with the wrong assumptions… ‘suicide is inevitable’, tacitly agreed by policy makers, silently absorbed by overstretched clinicians? These critical questions may go some way to explain a Depar tment of Health suicide strateg y consultation repor t that notes ‘ a degree of pessimism exists amongst (NHS) staff about the preventability of suicide’.This may well be a case of prejudice maintained by critical knowledge update gaps a failure to teach, rather than reluctance to learn.

What we know about what works worldwide in suicide prevention has expanded hugely this past decade although suicide prevention is miles behind research funding when compared with other causes of preventable death

We have to learn from moderate success at home and abroad, engaging zero suicide as the only target wor th driving for

people in our care . We must measure and evaluate ever y funded programme and cease investment for ser vices persistently failing performance excellence and governance stress-tests People at risk of suicide deser ve no less than excellent, compassionate 24/7 continuity of care as a fundamental human right

Suicide prevention has become the preser ve of NI Assembly Depar tment of Health Yet around 70 percent of people who die each year have had no health ser vice contact in the year preceding death Have we got it wrong promoting help-seeking from men under pressure , rather than focus on concerns closer to home? Picture the conversation over breakfast ‘I’m worried about you, have you been thinking about suicide?’ with the swift follow-up, ‘together we’ll get you through this difficult time I won’t quit until we get the best suppor t possible and you are safe and well ’

We all know mental health is the Cinderella of health care . Why? Until we generate a united, inclusive , influential suicide prevention movement, on a par with cancer care and road/air travel safety campaigns, then mental health and suicide prevention will languish in the twilight zone of pessimistic , poorly funded, poorly understood, anxious complacency

We have to find the path that unites all par ties around suicide prevention as an achievable goal We must dissolve per vasive myths… ‘it was his choice to die’ … ‘ we didn’t see it coming’ ‘there’s not much you can do when the decision is made she didn’t say ’ . People in suicidal distress communicate despair in many unspoken ways … relative withdrawnness, isolation, major life stressors bundling around a key time We need to be asking the questions, ‘ are you alright?… I am worried about you have you been thinking about suicide?’ and then stay around for the difficult conversations that accompany the answer

• Contact provide the secretariat to the NI Assembly All Party Group on Suicide Prevention.

How are we getting it so wrong when suicide seems impervious to 10 years of prevention ef forts?

‘’

Barrister Michael Mansfield and Yvette Greenway at St Mary ’s Training College in west Belf ast

It was a bluster y, wet Saturday as I made my way recently to St Mar y ’ s Training College on the Falls Road to an event organised by the Suicide and Awareness organisation in west Belfast.

I was there to hear a talk given by the renowned human rights barrister Michael Mansfield, who along with his par tner Yvette Greenway, have helped set up a group called Silence of Suicide (SOS).

Its aim is to encourage people to talk about suicide and was established following the death of Michael’s daughter Anna, 44, who took her own life in May 2015, after being diagnosed with depression

At the event Michael spoke about the need to confront the “elephant in the room ” and discuss more openly the issue of suicide

Afterwards, I asked Michael and Yvette about the progress of their group.

“The progress has been rather overwhelming in the sense that neither of us at the beginning realised just how great the need for such an oppor tunity as this was, ” said Michael. “The initiative has already in a sense rewarded the intentions but we need to keep it rolling out throughout the United Kingdom which is why we have gone to Scotland, into the Highlands The latest request has come from Manchester. There are a series of meetings coming up We’re coming back to Belfast in December and we ’ re hoping that will generate its own momentum The idea is not that we run it – the idea is that we oversee it and help people facilitate their own discussions ”

I asked Michael if his involvement in SOS had helped him in any way to cope with his daughter’s death

“Yes Without it and without Yvette –the two go together in a sense because we work together and live together – I think the accommodation which I’ll come to and, if you like , the recognition that I’ll come to vis-a-vis Anna is that it’s been much quicker and much more broadly based and deep-seated If I hadn’t had that I think I’d have been roaming around as a rather lost figure I mean, some people call it the grieving process, but I’m not sure whether that’s what it is. For me , it’s more I think coming to terms with something I

hadn’t really thought about before

coming to terms with the loss of somebody who I think about more now she’s dead than I did when she was alive So there are all sor ts of recriminations to myself about it all which would have loomed far larger and would have taken far longer for these demons to not disappear altogether, but to be diminished and put on the back-burner. So I think the process has allowed me space to grow into a new space for myself ”

Michael and Yvette have a meeting with Prime Minister Theresa May in November to discuss funding initiatives for suicide awareness

Yvette said: “What we want to speak to her about – apar t from the cuts and the fact there are people out there who are increasingly desperate to get some help that just isn’t available to them – we want to stress to her the impor tance of the work we ’ re doing

“As far as SOS goes, we need some kind of funding to continue our work – it’s just that simple . Because we don’t have deep enough pockets, we ’ ve relied upon Michael and the goodwill of the many people and the funds raised for us, which has been brilliant

“But, obviously to do all the

initiatives, to do all the administration, to do all the social media, it’s a full-time job and we don’t have the financial resources at the moment

“At the end of the day, the system is failing people . People are dropping into space basically with no help at all A lot of those people can’t continue waiting for help and they end up taking their own lives or they star t self-harming,” added Yvette “We need something constructive put in place – so people don’t fall through any loopholes They have quick referrals, they have access to almost immediate assistance , to counselling, without prolonged waiting times I know someone who has waited two years to see a psychiatrist ”

One of the things that Michael is eager to combat is the sense of hopelessness around the issue of suicide “I think that par ticularly at the moment the hopelessness that I am tr ying to touch upon is the way in which society is developing generally,” said Michael

“There is an alienation – there is a divorce between the haves and the have-nots – it really is quite serious

“We’ve been morally bankrupt for a ver y long time . People are struggling to sur vive on a daily basis I feel that is ver y prevalent and the politicians haven’t got it ”

Michael said his daughter’s rapid downward spiral in a matter of weeks before her death had aler ted him to the ver y fine line between coping and not coping with life

“Anna was a mar vellously energetic young woman, generous, inclusive and ver y loving towards her children,” he said

“She lived life to the full and always put others before herself If this happened to her, we are all vulnerable ”

He has called for more training for GPs and other health professionals to help them spot signs that someone may be having suicidal thoughts

• To find out more about Silence of Suicide (SOS), go to http://www.sossilenceofsuicide .org

• To watch a short film about their work go to

https://vimeo.com/152081055

L eading human rights barrister Michael Mansfield talks to VIEW editor Brian Pelan about why we need to confront the ‘elephant in the room’

Anna Mansfield took her own life in May 2015

the BIG interview

SDLP MLA Ma rk H Durka n talks to VIEW editor Bria n Pela n a bout his fond memories for his sister Ga brielle , who took her own life at 28 yea rs of a ge , a nd

Stormont – The House on The Hill

has vast labyrinths within it, which seem to stretch for ever and where one could –metaphorically speaking – be lost for good As Mark and I walked along the corridors to his office , I joked did he need a GPS map detector on his phone to find it? Mark laughed and jokingly replied “When I first star ted here it would have been a trail of breadcrumbs.”

The easy banter between the two of us made it slightly easier for my first question about his sister Gabrielle’s suicide and its effect on him and the people who loved and respected her.

“My sister Gabriella died just over five years ago, ” said Mark “She was a nurse , a ver y good nurse . When she died she was 28 years of age and was the youngest ward sister at Altnagelvin Hospital in Derr y She was highly thought off – by patients as well as her colleagues People still come up to me on the street to recount their memories of Gabrielle It's lovely to hear that she had such a positive impact on people . It's also ver y hard, though. I lost a sister and Altnagelvin lost an extremel talented, dedicated nurse

“Gabrielle’s raison d’etre was to help other people We can’t afford to lose people like that. We can't afford to lose anyone to suicide Gabrielle was the second youngest in a family of six We also lost our sister Deirdre in Januar y 2000 in a car accident Deirdre and Gabrielle would have been ver y close

“I have no doubt in my mind that Deirdre’s death would have stayed

with Gabrielle

“I can remember going through Gabrielle’s things in her room after she died and finding a huge amount of photographs of her with Deirdre .

“She had a ver y active social life She worked hard and she played hard She was renowned for her sense of humour and was also a great practical joker and mimic I was extremely close to Gabrielle We shared a ver y similar sense of humour and shared the same taste in many things, including films and comedy

“Sometimes I see something on TV and say I must tell that to Gabrielle and then I quickly remember that she is not there anymore It’s ver y difficult when you lose someone to suicide because you have lost that person and that person has left you It’s ver y difficult to get your head around it.”

What do you say to other families who have lost someone through suicide , I asked.

Mark replied: “When I speak to other people who have been bereaved through suicide , my best advice to them is always: don't ask yourself the question why, because there are no answers.

“I didn’t avail of professional counselling when Gabrielle died, although someone from a health trust did contact me , and I was also our par ty’s health spokesperson for some time

“I’m not sure that we as a family have ever properly come to terms with Gabrielle’s death. I don't think I will ever be fully reconciled to it or there will ever be total closure

“Since her death, I have listened to a lot of people who have lost loved ones through suicide ”

Mark’s warmth for his late sister is ver y obvious and he spoke openly of how he still deeply misses her.

“I miss my sister the most during happy occasions My wife gave bir th to a little baby boy recently. I’ve got married in the last five years These type of happy events are the sor t of thing that Gabrielle would have revelled in.

“It’s so sad that she is missing out on

he urged Stormont to devote more f unding to mental health services

I was extremely close to Ga brielle . We had a very simila r sense of humour a nd sha red the sa me taste in ma ny things

the things that would have brought her such happiness I recently put up a tribute to her on the fifth anniversar y of her death and a huge number of people commented on it and about how much that she meant to them ”

I asked Mark about Stormont’s Protect Life 2 strateg y, which is presently out for consultation, and his thoughts about the effectiveness of the Government’s suicide prevention strategies.

“It’s extremely difficult to gauge or measure a suicide prevention strateg y, ” said Mark “Although numbers taking their own lives have risen we don’t know how many deaths the strateg y may have prevented The rise in deaths, though, means there is a rationale for rebooting and revising the strateg y. ”

What should we do differently, I asked him

“There’s an awful lot we could do better and differently We need to listen to the people on the ‘coal face’, who are working daily with vulnerable people and the families who have been bereaved They know where the real shor tcomings are .

“I do know, though, that access to professional counselling ser vices is atrocious. It’s absolutely appalling right across all of the trusts

“We’re telling people that it's OK to talk to someone , but we are not saying that you will have to wait 12 weeks to talk to someone .

“The slice of the health budget which is allocated to mental health is appallingly low. We need a bigger allocation of funds instead of talk and honeyed words We

need to make more noise about it to effect real change At present, the vast bulk of the health budget goes towards addressing problems in emergency care and reducing waiting lists”

A six-person panel, headed by Professor Rafael Bengoa, was appointed last year by Stormont. It was asked to deliver recommendations on how health ser vices could become more effective and efficient.

Health Minister Michelle O'Neill outlined her response to the Bengoa

Health repor t recently

In a response to Ms O’Neill at Stormont, Mr Durkan said: “I ver y much thank the Minister for her statement and welcome the publication of this repor t, which contains some extremely sensible and necessar y proposals

“However, the lack of specifics in the repor t and in the statement on the transformation or rationalisation of our hospital estate means that a spectre of doubt will loom over ser vices in several areas ”

Mark H Durkan also said: (in his inter view with VIEW) “I would have liked and would have thought it to have been prudent if the minister had shared the repor t much earlier and received feedback to it. That could have helped inform her own response to it There has to be an increased focus on mental health and there has to be an increase in the budget for mental health

“I also don’t want the Bengoa Repor t to be a fig leaf for ever y decision that ever y trust or minister or depar tment makes over the next five to 10 years ”

Mark was ver y gracious as he thanked me for the inter view as we finished.

As I walked down the hill from Stormont I thought how easy he had been to chat with, especially the sharing of his fond memories for Gabrielle

She no doubt would have teased him a bit if she was still alive

She had a deep impact on him and the many other people who loved her. She is obviously still deeply missed

Happy memory: SDLP MLA Mark H Durkan with his sister Gabrielle

We're telling people that it's OK to talk to someone , but we a re not saying that you will have to wa it 12 weeks to talk to someone

In 2015, as we opened our new in-patient facility at Clock View Hospital in Liverpool, I shared our ‘wildly ambitious goal’ of zero suicides for the people in our care . Inspired by the work of Dr Ed Coffey, the Trust set about developing and implementing the Zero Suicide approach. For us the progress has been about the move from Zero Suicide as a concept to a set of practices

In this respect we have had some great successes in the 18 months: the Zero Suicide strateg y and policy was adopted by our board and we ’ ve developed a learning resource – a one hour e-learning module –which is now par t of mandator y training for all staff and has been completed by nearly 3,000 of our staff since its launch in April We have developed a ‘dashboard’ to monitor deaths from suicide , all clinical teams are suppor ted through investigations by the Safe from Suicide Team and we ’ ve been able to pick up themes and concerns and make sure that that learning is taken back to clinical teams

We’ve developed a learning resource for managers who carr y out the Family Liaison role , incorporating the lived experience of those bereaved by suicide –in fact the learning resources for all our training have been co-produced and incorporate Lived experience

As an organisation we are moving to a new understanding of the people who are dying from suicide; we understand that this year – to date , 11 people have died – who were either waiting to see us, or had been seen by us and had been identified as not having any mental health needs that needed to be addressed by our ser vices.

We have learnt from these incidents in a way that we would not have previously and are making changes to how we deliver ser vices as a direct consequence of these deaths, working with primar y care colleagues to improve the information we get at the point of referral, improving our clinical decision making both pre and post assessment, and offering additional clinical suppor t to those teams and individuals who are struggling

We are beginning to understand how

our training, ser vices and estate needs to be aligned to allow staff time to develop the skills needed to understand and treat the complex set of psychological, social and health factors which are par t of a suicidal crisis

Our clinical training is now at the pilot stage and includes simple risk formulation, safety planning and risk management training, but it will be followed up within the teams as par t of super visions, team meetings and our new information system will make it easier to document and share the risk information

When we announced our Zero Suicide vision one of the questions I was asked was, why? The National Confidential Inquir y into Suicide and Homicide (NCISH) benchmarked our Trust in the lowest quintile; so 80 percent of mental health trusts are worse at this than we are .

We provide ser vices in areas of high deprivation, some of the most deprived areas in the UK in fact, and Southpor t has one of the highest rates of suicide in the UK, so are we not embarking on an impossible task?

What I am seeing throughout the organisation is a commitment to making that impossible task happen; the take up of the level one training has been incredible , from the board to the floor, staff have come forward to share their own stories of bereavement, of being suicidal and become par t of the learning resources

Individual clinicians and teams are beginning to access suppor t from the Safe from Suicide Team to suppor t and enhance clinical decision-making and ser vices are using the exper tise of the team as they reconfigure or design new ser vices

Suicide prevention has become par t of ever y conversation about how we move our ser vice forward and difficult and challenging conversations are happening with ser vice leads and with individual clinicians about how we can improve the care we deliver and how we can learn from tragic events

• Joe R af ferty is a guest speaker at Contact Suicide Prevention: What Works? Conference on November 17, Titanic Belf ast

Why Zero Suicide approach is working

Joe Rafferty, chief executive at Mersey Care NHS Foundation Trust, says his organisation has had some great successes since implementing the Zero Suicide strategy

‘’ Suicide prevention has become par t of ever y conversation about how we move our ser vice forward

Prison deaths

Suicides a nd assa ults a re at a n all-time high in prisons in Eng la nd a nd Wales. VIEW editor Bria n Pela n asks Northern Irela nd Prisoner Ombudsma n Tom McGonig le a bout the state of mental health in our ja ils

Question: What's your assessment of the state of mental health in our jails?

Answer : Tom: It’s a concerning matter We frequently find prisoners with poor mental health The Care in the Community policy introduced in the early 1980s which was aimed at reducing the population in our psychiatric hospitals has to some extent contributed to an increase in the prison population

Q: What are the latest figures for death by suicide in Northern Ireland prisons?

A: It’s the coroner who will finally determine the cause of death We will talk about the probable cause of death The figures that I have since this office was set up in 2005 are 67 deaths in custody that have been notified to us Just under 40 per cent of those would have been self-inflicted, some would be classified as probably misadventure due to people taking too much medication or overdosing on drugs You can’t say whether or not they intended to die And then the rest were due to natural causes.

Q: Are you satisfied with your remit and powers and do you have adequate resources?

A: Essentially, yes. I think the remit is correct The remit of this office is twofold: it is to investigate prisoners’ complaints if we ’ re not satisfied with the Prison Ser vice’s response , and to investigate deaths in custody. We have the right level of resources to do that in terms of the numbers of deaths in custody that we are asked to investigate .

Q: In a recent report, you expressed dissatisf action with delays in getting material for

investigations from the Northern Ireland Prison Service (NIPS) and the South Eastern Health and Social Care Trust. Can you discuss these delays, and has the situation improved?

A: The delays are essentially down to the fact that the Trust and NIPS will say to us that they have a range of operational priorities to address, including front line deliver y of healthcare ser vices, and for NIPS, the deliver y of security for prisoners. They do provide the information we request but sometimes it is ver y slow The problem with that is that it undermines the effectiveness of prison oversight It means that bereaved prisoners’ families are waiting a long time because the inquest won’t take place until our investigation is completed There have been no noticeable improvements, I have to say

Q: Should prisoners be able to complain to the Ombudsman without first going through internal procedures?

A: No. I think it’s correct that the prisoner should first of all go through the Prison Ser vice’s own internal complaints procedure .

Q: Are you satisfied with the Prison Service response to your recommendations, and specifically in regard to mental health and suicide .

A: Last year NIPS accepted around 83 per cent of our complaint recommendations There are times when we have to agree to disagree . The philosophy of this office is not to make life difficult for the Prison Ser vice and the Trust but to tr y and help them to do things better

Q: In light of the recent shocking Sean Lynch case (a report by your of fice said that Sean Lynch inflicted “extreme and shocking” self-harm over three days. The 23-year-old was held in Maghaberry Prison. Mr Lynch’s f ather said the recommendations in the report of fered “no comfort”. The report said on the final day, two prison of ficers watched as he injured himself on more than 20 occasions in an “ordeal” that lasted for over an hour), why are so few warders disciplined following criticisms of their actions?

A: I can understand the emotional reaction from people that heads must roll But there are a couple of things to bear in mind in that case . Firstly there is the prison governor ' s order that you only go into a cell if a prisoner is bleeding profusely or is hanging or in a collapsed state . None of those applied in Sean Lynch’s case There was a huge failure in duty of care in this case The problem is that there are contradictor y and conflicting rules That anomaly has to be rectified. The authority in my office is limited to making recommendations We can’t enforce the recommendations we make .

Q: Is it frustrating that you don't have powers of enforcement?

A: It is frustrating and I have expressed that frustration I have made recommendations and people say that lessons have been learnt, but it appears that lessons have not been learnt

Q: Would you like to have powers of enforcement?

A: The most powerful weapon I have is the power of publicity

Q: Given the number of self-harm cases, should prisoners with mental health problems be held in jail?

A: That’s for politicians to decide

Q: But what do you think as the Ombudsman?

A: There are cer tain people , who as a lay person, I think on the face of it, belong more in a psychiatric institution than a prison. But a criminal cour t has decided with all the evidence in front of them that that person (Sean Lynch being one of them) was properly and legitimately to be remanded in custody It's not for this office to investigate or determine a district judge’s deliberations

Q: Does the Ombudsman's of fice have an opinion on it?

A: I have an opinion on lots of things

Q: I understand that your powers are limited. But what I'm trying to find out is do you have an opinion on the number of people with mental health issues, including at risk of suicide, being held in our jails.

A: Yes. There are a lot of people who are in jail who would be better looked after in a psychiatric institution But a criminal cour t has decided with more information than I

have that they are correctly placed in jail

Q: Have things improved in prisons?

A: Some things have improved and some have not There's no doubt that the Prison Ser vice and the South Eastern Trust find themselves increasingly strapped for cash and the Prison Ser vice has less staff to manage and look after troubled prisoners The South Eastern Trust also has difficulty in recruiting staff to work in prisons.

Q: Is it a f air description to say prisoners who are caught in a cycle of depression and substance misuse are having to rely on prison of fers with limited training and mental health staf f with limited resources to care and support them?

A: I think it is A prison is a ver y difficult place to live and work in, and if you add mental ill health into that mix, it can be quite volatile

Q: What is you view on the Supporting Prisoners at Risk (SPAR) process in NI jails

The SPAR process is fine But too many prison officers and health care staff view it as a box-ticking exercise SPAR was never designed for such an extreme case as Sean Lynch. It has become a bureaucratic stick

for prison officers rather than something that could be quite helpful

Q: Is it a tough job to speak to f amilies who have lost someone in jail due to suicide?

A: It is a tough job but it's an essential par t of it Families are a key stakeholder in what we do A major par t of our deaths in custody investigations is to make sure that any queries or concerns they have are answered

Q: Are you optimistic or pessimistic about the f uture?

A: If I look across the water, such as in England and Wales, then I would have to be concerned All the data shows an increase in deaths And while it can’t be proven, I have no doubt that it’s due in par t to their budget being hugely cut and they have lost staff If that happens in Nor thern Ireland and we lose prison staff, then it means it will be less likely that an officer will get there in time if someone takes a hear t attack or tries to hang themselves So yes, I am concerned

Is our present prison regime fit for purpose?

A: It’s what we as a society have Our prison system in Nor thern Ireland is a modern Western system, but it’s coping with people who have increasingly complex issues.

Concerned: Northern Ireland Prisoner Ombudsman Tom McGonigle

A father’s pledge

Eighteen months ago I stood next to my beloved son ’ s coffin in church and made a public promise before several hundred people to investigate his appalling death and the mental health sector in this countr y I promised that I would seek reform on his behalf

Born in Cambridge , Edward Mallen was an academically and musically gifted 18-year-old who took his own life in Februar y 2015 following an unexplained, rapid and catastrophic onset of depressive illness Edward was a leader of his school council, a head boy at his primar y and secondar y schools, and a talented classical pianist

My son was a popular and friendly young man who had recently been offered a place at Cambridge University. He enjoyed travelling, played cricket for the local team, delivered the newspapers in his village and worked at weekends in a Cambridge bookshop

Deeply rooted in his community, Edward was from a stable and loving home and a close-knit family With no histor y of trauma or difficulty, he fell into psychotic

despair for no apparent reason just weeks before he died

His case reminds us that mental illness is a cruel disease which can affect anyone , regardless of background

Over the past 18 months I have worked my way through the UK mental health system, consulting with politicians, academics, health professionals, charity executives and community health managers, together with countless other bereaved families and those living with psychological trauma

The MindEd Trust was formed a year ago in honour of my son (www.themindedtrust org) Intense media interest and my personal mission have afforded Edward and the Trust a par ticularly high profile

A conference held at Cambridge University in March this year attracted senior figures from across the political and health sectors and the leadership of the mental health community.

From a position of blissful ignorance , what I have discovered these past months beggars belief and has shaken the ver y foundations of my belief in an empathetic health system and a caring society. With

regard to mental health, sometimes the world is as terrible as one fears it might be

In Edward’s case , the systemic failings were so profound as to lead the Coroner to produce a Regulation 28: Prevention of Future Death Notice under the Coroners & Justice Act (2009)

There is little need here to rehearse the compelling litany of damning statistics which characterise mental health in this countr y as they are now repeated, mantra-like , across the sector

Whether it be the 75 per cent origination of mental illness in the pre-higher education age-group which attracts only 10 per cent of mental health funding (representing just 0 7 per cent of the NHS budget) or the derisor y three per cent of the Medical Research Council (MRC) budget spent on mental health research in 2014-15, the numbers relating to mental health are , quite simply, an indictment on our society and are symptomatic of a care system which is, for the most par t, patently not fit for purpose

So, from my viewpoint, amongst the

Steve Mallen expla ins why he is ca mpa igning for urgent reforms to mental health provision throughout the United Kingdom a fter his 18-yea r-old son Edwa rd took his own life

Steve Mallen beside messages of sympathy after the death of his son Edward

myriad array of relevant themes, what are the mission critical issues? How can we save lives and alleviate suffering quickly in a woefully inadequate and fragmented system?

• Consent and information sharing. Hundreds of lives have been lost and hundreds of thousands are suffering unnecessarily owing to completely confused and ambiguous protocols surrounding information exchange . With absurd waiting lists for therapy throughout much of the countr y, the care and treatment of those suffering from mental disorder could be radically improved by empowering families and carers with the information and resources they require to enhance the life paths of those in trauma Even within the NHS, information and record transfer is haphazard, most especially and critically, at the adolescent/adult interface Completely new, enforceable and sanctionable protocols are needed

• Anti-depressant medication. The rapid escalation in psychopharmacological prescription rates involving medication with known risks of increased suicide

ideation is of grave concern. A systemwide review and procedural reform are now essential

• Clinical risk assessment models are haphazard, with wide regional variation Self-harm and suicide risk assessments are largely based on processing speed and box-ticking

Surrounding these specific themes is, of course , the parlous state of the NHS in general and its structural dysfunction with regard to mental health.

The austerity climate has resulted in the savage cur tailment of community and local authority funding and resources which are aimed at awareness, prevention and early inter vention

This in turn places an intolerable strain on the school and the family system. I would like to close with a final thought

Why do we not give the NHS less to do in the first place?

Mental illness is, for the most par t, entirely treatable and the vast majority of sufferers can go on to fulfilling life paths if problems are detected early and inter ventions made effectively.

One way to save the NHS would be to restructure mental health care towards education, prevention and early inter vention and aver t the psychological crisis in the first place The moral and fiscal arguments are totally compelling

In dealing with my bone-crushing grief these past months, I have often been invited to think of my son ’ s death as some terrible , random accident This is not so As his own medical records note , he had an entirely treatable condition and ever y prospect of a complete recover y If the mental health system in this countr y were anywhere near fit for purpose and if our collective mental health literacy as a society were better, he would still be alive

It is that simple

• Steve Mallen, who is a guest speaker at Contact Suicide Prevention: What Works?

Conference on November 17 at Titanic Belf ast, is chair of The MindEd Trust

(http://themindedtrust.org)

If the mental health system in this country were a nywhere nea r fit for purpose a nd if our collective mental health literacy as a society were better, he would still be alive . It is that simple

Edward Mallen, who took his own life in February 2015

A family’s devastation

Ca rolyn Done wa nts a revie w of ‘client confidentiality ’ a fter her son La wrence took his own life in 2010

Suicide within a family is devastating

But when the victim is your child, you blame yourself

As a mother, you give life to and nur ture your baby, watch them grow, help them to learn and, above all else , you protect them and keep them from harm. When a child takes their own life you feel that you have failed – failed at the most basic human and animal instinct: to protect your offspring

At school, when my little boy Lawrence grazed his knees in the playground, bumped his head on an open window, and scratched his hand on a thorn bush, I was informed and the incident recorded in the school’s ‘accident’ book

Even when he was 18 and a bearded university student, I was the one who took him to hospital to have his tonsils removed. I did what any parent would do.

In 2010, Lawrence was studying physics at the University of Birmingham and experiencing life away from home for the first time Although only a 40-minute train journey away, he lived in halls of residence , sharing a flat with four other students I saw him at least once ever y for tnight, and although I knew he was upset at the break-up of his first serious relationship, there were no signs that he was struggling to cope with his studies, or not enjoying university life

He appeared to be the same quirky teenager who made friends easily and faced challenges full-on

On Sunday, March 21, 2010, Lawrence failed to come home for lunch with the family Frantic , I drove to Birmingham and his halls, where an ambulance and police car were parked and I was given the news that our beloved son was gone . It was another 24 hours before we discovered he had completed suicide Nothing could have

prepared me , or any of his family, for that.

Five months later, in August 2010, we attended an inquest into his death where an open verdict was recorded. Birmingham Coroner Aiden Cotter said that ever ything possible had been done by health care professionals to suppor t Lawrence , following a university doctor diagnosing him with depression and prescribing anti-depressants

At the inquest the GP had legal representation. A representative of the university’s counselling ser vice gave evidence on behalf of the counsellor ; a statement was read out from a doctor who had admitted Lawrence to hospital following two incidents of self-harm, and another statement was read from the university tutor in whom Lawrence had confided.

As a family, myself, my par tner, and Lawrence’s father sat completely dumbfounded that all of these people knew that our child was suffering from mental health issues Not one of them had contacted any of us, or identified us as a ‘safety contact’.

Just one month after star ting university, and following the break-up with his girlfriend, Lawrence made his first suicide attempt We were not informed The reason we were given was that he was an adult and all of the professionals involved had a duty to respect his confidentiality. Had Lawrence been involved in any sor t of accident then I would have been contacted immediately, but because his admission was a mental health issue the veil of confidentiality came down

Did we as a family – or me , specifically, as his mother – fail him? We failed to see his suffering, but when he was around us he was the usual ‘Loz’ we all knew and loved Did the university fail him? Yes, they should have informed his emergency contact/next-of-kin that he had expressed suicidal thoughts

As a family we felt that the ‘professionals’ closed ranks to protect themselves In the weeks leading up to that awful day, and the months before the inquest, their self-protective instincts mattered more than the duty of care they had towards protecting our son Lawrence , a caring, funny, intelligent young man with a whole lifetime of adventures in front of him

• Carolyn Done is a guest speaker at Contact Suicide Prevention: What Works? Conference on November 17 at Titanic Belf ast

Lawrence ( f ar right, aged 12) with his step-f ather Steve, his mother Carolyn, older brother Alex and sister Izzy in 2003

Student Lawrence Stirk, who took his own life in 2010

High price of austerity policies

Ulster

Suicide was historically believed to be primarily a mental health issue , with suicidal thoughts indicative of depressive illness However, it is now well recognised that most people who have a mental illness do not seriously consider suicide

Research demonstrates that the factors related to suicidal behaviour are strongly related to the experience of life crises

It is feelings of despair, hopelessness and entrapment that best predict suicidal thoughts and behaviour, not the extent of mental illness We know that those who end their lives are ver y frequently acting in response to a life situation in which death is a viable option because the pain of living has become too great and there is no hope of a way through the problem

Psychological autopsies under taken following a death frequently reveal immense suffering accompanied by fears of shame , loss of dignity and isolation.

Financial insecurity and the prospect of the loss of income are increasingly obser ved among the life events that precede suicide . The loss of employment, income , status or ability to fulfil social roles heighten suicide risk, and social and economic policies have an impor tant role to play

If we are serious about suicide prevention in Nor thern Ireland we need to work together to reduce the likelihood of people here experiencing the types of crises that lead to suicidal thoughts

Research in the wake of the global recession has demonstrated that it has led

to an increase in suicide rates in several countries In Ireland, there has been an additional 961 deaths from 2008-2012 that are directly attributable to the recession, and impor tantly the austerity measures implemented in response to the recession

The data from Ireland and other places illustrate that the decisions made about the ways in which the incomes of the most vulnerable are protected have a direct impact on suicide rates

Unfor tunately, the economic recession is a reality that our politicians need to grapple with, however decisions are made about how the remaining funds are allocated, and we need to face the reality that these decisions have an impact on whether people believe their own lives are wor th living

In Nor thern Ireland, those who live in the most deprived areas have three times the average rate of suicide Welfare reform and the removal of incomes from vulnerable marginalised groups who are already over-represented in our suicide statistics can only exacerbate this trend

Suicide prevention is about much more than mental health and asking people to seek help if they are suffering It is about tackling the social injustices that create life crises and mental health problems in the first place and protecting people who are vulnerable It is about creating lives wor th living

• References – go to http://viewdigital.org/2016/08/14 /references/

University professor Siobhan O’Neill says that those who live in the most deprived areas have three times the average rate of suicide

‘’

It is about tackling the social injustices that create life crises and mental health problems in the first place and protecting people who are vulnerable . It is about creating lives wor th living

Focusing on the positives

My name ’ s John Mallon, I’m 52 years of age The reason why I have a photography exhibition, called ‘Beauty On Our Doorstep’ at the Kennedy Way shopping centre in west Belfast, is that it’s a means to an end to reach out to people with mental health issues

I came here nearly two years ago. The response and suppor t has been absolutely amazing

People come up to me and talk about themselves Some are in a pretty bad way, but thankfully I have done signposting training and I’m able to direct them to the right place for help

Mostly it would be Lifeline because of the 24-hour ser vice it provides I remember one day giving a man a Lifeline card. About two months later he came up to me to say ‘thanks’ At first I didn’t realise what he was saying but then found out that he had contemplated ending his life He told me that he had found the card I had given him in his pocket and had rang for help and had got the suppor t he needed I still see him regularly and he now seems to be enjoying his life once again.

I grew up in Ballymurphy in west Belfast I was bullied at primar y school, which had an effect on me There could have been any number of reasons It just happened one day – I’m not sure exactly

why but I was just given this name ‘Flea’ and it stuck with me for over five years at school

I was married but I’m now separated I have five children of my own About 22 years ago I star ted to become aware that something wasn’t right about how I was feeling I initially laughed it off A lot of people knew me as ‘Big Tough John’, but I had a problem that I was not dealing with

I would drink alcohol at night, but that just compounded the feelings Throughout the day ever ybody would see happy-golucky John, but I was suffering from depression and had a growing desire to end my life . Some days I would have gone for a walk around shopping centres – not to buy anything – it was to tr y and get away from my depression

My life was getting worse and becoming more and more painful

You know, I’ve often seen people talking about having pain from different illnesses – I can assure you that this was a ver y, ver y tough pain I woke up one morning and I just decided my life was going to end, so I went and visited my children They thought their daddy had just come to see them, but I was there to say goodbye because I had this horrible feeling in my head that I was going to be dead within 24 hours.

I got up the next morning and took more alcohol. I got into my car and drove until I came to a crossroads, if I turned left, that’s where I was going to die . I knew it well as I often walked there I don’t know how long I sat there I managed to drive the car forward and I turned right.

I got great suppor t from a couple of individual men and a fantastic woman counsellor. My advice to people is if you ’ re going to talk about your problems, talk

John Mallon, who has battled depression in the past and who once contemplated suicide, tells VIEW why his love of photog raphy has given him a renewed passion for life and a willingness to help others with mental health problems

about them – war ts and all

What you will find is the more you talk about it, the easier it becomes I used to think I had a big sack of stones on my back, but the more I spoke about my depression, the bag became lighter

I then star ted to work with the PIPS charity (Public Initiative for Prevention of Suicide and Self Harm) After I left PIPS I was doing various jobs and I was still doing some photography People would say to me: “John – you should do an exhibition –

your work is fantastic ” I then met stills photography Jason Bolan who had worked on a lot of major films I showed him some of my images and he said I should “follow my dreams”

Photography is a way of reaching out and I can do it through beauty. I can use it as a means to star t a conversation People come to me all the time If anybody is in immediate needs of help I always give them a Lifeline card

I also speak about my experiences at

events organised by Contact

The beauty of this countr y is so immense and that’s why I call my exhibition Beauty On Our Doorstep. I don’t have to jump on a plane and fly a million miles away to see it

I can go shor t distances in any direction in Belfast I can be somewhere where there is beauty, such as a park

I love to tr y and capture a beautiful image and then come home and share it on social networks for people to see it

John Mallon beside his photog raphy exhibition at the Kennedy Way shopping centre in west Belf ast

Bea uty On Our Doorste p

Image: John Mallon

Bea uty On Our Doorste p

Images: John Mallon

If you, or someone you know has been af fected by any of the articles and interviews in this edition of VIEW, remember Lifeline the crisis helpline is available 24/7 on 0808 808 8000. All calls are free from landlines and mobiles and all calls are answered by qualified crisis counsellors.

Above: Tyrella Beach, Co Down; and below, a view over Belf ast at night

Why having support is vital

Stephanie Green, a development worker with the organisation Participation and the Practice of Rights (PPR), urges backing for SAFER (Support Automatically For Everyone Referred) campaign

Over the past decade , family members and friends exposed to suicide have shown courage and determined leadership in effor ts to prevent fur ther deaths

This is demonstrated by their successful calls for a suicide prevention Protect Life strateg y, campaigning for a 24hours helpline ser vice , changes in appointment systems at A&Es such as the ‘card before you leave’ appointment system and the inclusion of information on mental health ser vices in the government’s Choose Well public information campaign to name but some

Since 2006, Par ticipation and the Practice of Rights (PPR) has suppor ted families bereaved by suicide , mental health ser vice users and carers to lead innovative human rights campaigns to make improvements to the ser vices they receive In 2014, they won the Steve Pittam social justice award for their campaigning work.

Bereaved family members more recently have also taken the lead in highlighting that access to information and suppor t following bereavement is not always timely and indeed many families are missing out altogether. This is ver y worr ying as this group is especially vulnerable themselves as the following health research shows:

“Family and friends of someone who takes their own lives are up to three times more at risk of taking their lives and to experience severe effects on their health, quality of life , ability to function well at work and in their personal lives ” –http://bit ly/2fcvZJm

Measures to improve access to suppor t and information in a timely manner is a key component of any suicide strateg y

Family members highlighted problems accessing suppor t at the launch of their new campaign ‘S A F E R ’ (Suppor t Automatically For Ever yone Referred) with the suppor t of human rights organisation Par ticipation and the Practice of Rights (PPR).

Since 2011, a new system has been in place to connect families into suppor t systems, for example , post-bereavement and suicide prevention organisations and, according to family members, this system can be ver y effective . The Sudden Death

(SD1) Notification system is utilised by the PSNI to inform the Public Health Agency and health trusts of suicides and requests by family members for suppor t.

Unfor tunately, this system has its flaws, For example , if someone dies in hospital following a suicide attempt there is no process for linking these bereaved families into suppor t systems, thus many families are missing out

Another issue identified, and confirmed through a Freedom of Information request, in the SD1 process is that in Belfast Trust area only 50 percent of families are taking up the offer of suppor t

In focus groups, families identified the timing of the police officer asking for consent to pass their details to suppor t groups as an issue Families often felt they did not know what they wanted or needed at this time due to the traumatic nature of their loss

Fur thermore , some family members raised concerns that the police did not know the nature of the suppor t being offered and were anxious about statutor y organisations like social ser vices perhaps being involved.

Delays in the police passing the relevant forms to suppor t organisations were also identified. An east Belfast suppor t group found that only three out of 12 individuals who did request suppor t were contacted within the time specified in the guidelines of 48 hours A number were not contacted for up to two weeks.

The SAFER campaign offers simple solutions to potentially overcome the issues highlighted:-

• An automatic referral for suppor t through the Sudden Death (SD) process An automatic referral policy already exists with Victim Suppor t and so the principles (and solutions to obstacles such as data protection) could be applied here Briefly then, an ‘opt out’ system as opposed to the present ‘opt in’ one .

• A newly formulated referral process comparable to an automatic SD referral process for death in hospital following admission following a suicide attempt

• A long-term goal of automatic referral to coroner ’ s office for bereavement suppor t A similar model works successfully in New South Wales, Australia.

For more information please contact stephanie@pprproject org or visit www.pprproject.org

‘’ Measures to improve access to suppor t and information in a timely manner is a key component of any suicide strateg y

Individual approach needed

Philip

You just don’t wake up one day and become a racist – a commuter says to his passenger, a fellow commuter in ‘The Commute’, a recent TV programme I immediately thought this fits with my own take on suicide , namely, an individual’s pathway to death by suicide does not emerge overnight: it’s a dynamic if dysfunctional response to their unbearable , ongoing psychological, social, biological predicament

Research by Joiner (2005) identified an essential factor that’s present in each suicidal death, namely the victim’s ability to kill themselves, or ‘acquired lethality’: the soon-to-be-deceased must have taken the time to learn how to do it

Shneidman (1971) and Maris (1981) have suggested that each victim’s death by suicide might represent the tragic conclusion to a lifelong journey, long or shor t, that morphed into a fatal trajector y

On a positive note , this scenario suggests that multiple oppor tunities may exist, for the person at risk, and for their relatives, carers, friends, neighbours, colleagues and clinicians to inter vene and influence the potential victim’s deadly intentions and terminal destination

It’s like if ever ybody else did something different, then this person would not, or could not, or might not, take their own life Does this matter? Nothing matters more since failure to act upon such oppor tunities can be fatal for the vulnerable individual at risk

Each death by suicide is as unique as an individual’s fingerprint Learning to recognise and act upon the ‘signs of suicide’ represent impor tant objectives for awareness-raising effor ts by suicide prevention organisations and individual helpers Almost 50 years ago Shneidman listed some high-profile ‘markers ’ , or indicators for suicide ideation or suicidal behaviour, including conspicuous instability, depression and problems in relationships, especially early ones

These days, most if not all that’s written about suicide prevention includes schedules of signs, or symptoms, for suicide risk A fairly random Google search for ‘signs of suicide’ identified 25 of these in four categories: behavioural, physical, cognitive and psychosocial: there’s nothing simple about suicide

Regrettably, professionals and volunteers in suicide prevention work will be relatively ineffective without considerable exper tise in understanding, recognising and acting upon these signs. I would argue that developing and maintaining such exper tise demands focused education and training in suicidolog y and psychotherapy, initially to cer tificate/diploma/master’s level and then by continuous professional development. Two-day courses with occasional refreshers will not do It seems self-evident to me that what you don’t understand you’ll find ver y difficult to change

Unfor tunately, there are many combinations of suicide ‘symptoms and signs’ Research has not identified, and may not ever identify conclusively, which individual ‘symptom’ or group of ‘symptoms’ might accurately predict a death by suicide

To date , neither blood test nor brain scan can conclusively confirm a person ’ s propensity towards suicidal behaviour in the shor t, medium or long-term This is because suicidal behaviour’s neurobiolog y represents a most serious problem in both psychiatr y and general medical practice that remains to a large degree unclear Perhaps the best that can be done by experienced helpers for an at-risk individual is appropriate , compassionate engagement, offering genuine , empathic , non-judgmental suppor t, including when available and appropriate , exper t psychological guidance

To sum up. Suicide is a highly complex, perhaps the most complex, human behaviour. Each incidence of suicidal behaviour, I would argue , is a unique phenomenon unlike any other

Yet medicine , including psychiatr y, currently expends scarce research resources in a desperate if futile search for similarities, commonalities and degrees of sameness in suicide-related cases Why futile? Because of that idiosyncratic ‘unique factor’ Better perhaps to emulate a leading local legal organisation that acknowledges individual differences by aspiring to treat ever y client as an individual

• To access references used in this article, go to http://viewdigital.org/2016/08/14 /references/

Consultant in psychotherapy and suicidology

O'Keeffe, who lost two family members to suicide, argues that a high level of expertise is needed to understand, recognise and act upon key symptoms.

‘’ Suicide is a highly complex, perhaps the most complex, human behaviour. Each incidence of suicidal behaviour, I would argue , is a unique phenomenon unlike any other

My son was good looking, warm-hearted and funny ‘ ’

Saagar was 20 years of age when he took his own life A bright young man of Indian origin, he had spent the first five years of his childhood in India, the next seven years in Belfast, and then he moved, with his family to London.

He was a gifted drummer, cricketer and linguist He played drums in a band and was a fast bowler in his college cricket team He spoke English, French and German fluently and was learning Arabic . He was good looking, warm-hear ted, funny and genuinely interested in people He valued his friendships and had a lot of time for his friends He was funny He did all kinds of accents and mime and always had ever yone laughing.

Saagar had just completed his second year at university with good grades He was home for summer holidays before commencing his third year at Brussels where he was to study French.

But one day his behaviour turned erratic and he was taken to A&E He was diagnosed with ‘hypomania’ and handed over to a Home Treatment Team He was star ted on Olanzapine 5mg and began to show improvement

A diagnosis of bipolar disorder was made by a consultant psychiatrist. He did not speak to us about the diagnosis and its implications for the family

Three weeks later Saagar was better and was discharged to the GP to facilitate his education abroad Within days he star ted to get depressed, but he still went abroad to star t his third year at university

He was unable to cope and had to be brought back home within 48 hours of his depar ture We took him to the GP on the day of his return.

They were concerned about him and requested a referral back to the psychiatrists, but the GP reassured us and advised us to take a week off work and take care of him at home

His PHQ-9 scores (severity of depression) were not shared with us He was seen by the GP ever y two weeks. He was star ted on Citalopram, 10mg, once a day Saagar then repor ted a minor setback

As parents, we were ver y concerned but once again we were reassured and Citalopram was increased to 20mg per day No warning of side-effects was given.

Two days later Saagar ended his life , just 10 weeks from his first visit to A&E

• There was a general failure to identify the diagnosis on the discharge summar y from the Home Treatment Team to the GP.

• There was a general failure to communicate thoroughly enough with the parents about the relapse symptoms, what to watch out for and where to go for help in the future

• There was a failure to assess Saagar’s risk of suicide in more detail and give more consideration to referral to secondar y care and discuss the same with his parents given that his PHQ-9 score was 27/27

The discharge letter from the psychiatrists did not mention a working diagnosis Neither did it clearly state the warning signs to look out for It warned the GP to look out for a ‘relapse’

The Home Treatment Team discharged Saagar without any route to come back to specialist ser vices in case of deterioration

The GP said in cour t: ”Suicides are not predictable or preventable ” He went on to say that he was not made aware of Saagar’s diagnosis by the Home Treatment Team He was treating Saagar for unipolar depression

He insisted he had a safety plan in place when in reality he had not uttered the word ‘suicide’ in our presence . He only used the word ‘crisis’

Human factors played a major role in Saagar’s death. Those critical human factors included failure to communicate Saagar’s known suicide risk in a meaningful, direct way with his parents; failure to distinguish between patient confidentiality and secret keeping, when our son ’ s life was at grave risk, and failure to include Saagar’s loving, capable family in his safety plan

I hope this tragedy will shed some light on the impor tance of clinical human factors in patient safety when we rightly regard suicide as a preventable harm in crisis care provision, and when care systems include loving suppor tive families in patient safety planning as essential therapeutic allies

• Dr Sangeeta Mahajan, who writes a blog at www.kidsaregifts.wordpress.com, is a guest speaker at Contact Suicide Prevention: What Works? Conference on November 17, Titanic Belf ast

Dr Sangeeta Mahajan calls for more information and support to be made available to f amilies following her son Sagaar Naresh’s suicide in 2014

A mother’s appeal: Dr Sangeeta Mahajan, and her son Saagar

By Brian Pelan

The Niamh Louise Foundation was set up in Februar y 2006 following the death of 15-year old Niamh McKee , who died by suicide on November 21, 2005.

I spoke to Niamh’s mother Catherine McBennett recently in the front room of a bungalow in Dungannon which the foundation uses for its suicide awareness activities. I star ted off by asking Catherine how she was feeling now

“Well, I suppose the main thing from the foundation is that we believe that you can recover, ” said Catherine “You can recover from the bereavement It’s not to say that you ever forget or that the emotions fully go away – they don’t You’d be lying if you said that it doesn’t affect you People torment themselves when they come in here and say that their lives have fallen apar t as a result of the death of a loved one

“In the early days after Niamh’s death I could only function at maybe 20 to 30 per cent When it happens your whole world falls apar t and you completely shut down You look at life completely different – life is not the same ”

How did you keep going, I asked.

“You have two choices I say the same to all grieving families: you either lie down and die or you do something – you tr y and help yourself, or the best par t of recover y can be helping others So that’s the ethos of the foundation and I still live by that

“But it’s not easy 11 years on – it’s still not easy. Ever y day, if I need something for the foundation or I need a worker or I need money, I will say: ‘All right Niamh, you ’ ve got to get your act together’. So all the inspiration comes from her I also have a great belief in God ”

Catherine said that her background is ar t and design, but after Niamh’s death, she said she didn’t have the desire to work at it “I have my own studio at home and it’s still there I’ve maybe cleaned it two or three times but I haven’t gone back to it. You just can’t It’s not to say that 11 years on that I want to So I’m sor t of thinking, right – retirement, whenever that comes, that’ll be something I’ll have

“My passion lies now in creating awareness I’m also ver y big now into self-care But I didn’t have anybody with the knowledge of recover y when Niamh died ”

Has your foundation had an effect in raising awareness around suicide and

mental health, I asked her.“We know we have had an effect because of the amount of people that come to us, ” replied Catherine . “We don’t do a lot of adver tising, but that’s only because of resources We need more people in the community to highlight the issue of suicide

“We need the media to use the word ‘suicide’ and stop it being a dir ty word.”

Is there still a stigma surrounding the issue of suicide?

“You’re absolutely right – there is still a stigma – there is a shame associated,with it But there are still too many suicides –this has to stop – we have to do something This is a family issue – we need to educate the mother, the father, the sisters, the brothers

“I was talking to a young mother recently. I said: ‘This is too hard to do on your own – this is too hard for any parent to tr y and cope with their child or someone within their family or husband or wife When a family does come in here I give it the whole family approach. I am going to be honest with them ”

• To get more information The Niamh Louise Foundation, go to http://www.niamhlouisefoundation.com

Catherine McBennett set up the Niamh Louise Foundation in the wake of her daughter’s death

I think of my father every day

Author Tony Macaulay, who wrote the successful book Paperboy, describes his feelings after discovering his dad’s suicide note tucked away at the back of his late mother’s Bible

Afew weeks ago my mother died. It was one of the saddest days of my life but it wasn't a shock My mother was 83 years old and for the last 10 years of her life she endured a long and debilitating journey with cancer

In the final hours of her life we held my mother’s hand, mopped her brow, played songs to her, comfor ted her and prayed with her We told her not to worr y about us, we said it was okay for her to let go, and most of all we told her just how much we loved her

On the night she died, as I left her bedside , I felt I needed to take something of hers with me before I kissed her goodbye I lifted the Bible that always sat on her bedside table and took it home with me that night

When I got home I opened my mother’s Bible At the back of the little black book I found a small plastic wallet with an assor tment of fragile yellowed newspaper clippings, which had been carefully cut out from the death notices of the Belfast Telegraph over a period of 40 years

I found the death notices of my granny and granda and all those dear family and friends that had passed on before my mother. But then, hidden behind this loving collection of memories, I noticed a ver y different piece of paper, a small scrap of blue paper with torn, irregular edges, folded over once

I knew immediately what I had discovered It was my father’s suicide note It was exactly as I remembered it from the first and last time I had read it on May 20, 1986

It was a handwritten message to my mother, scribbled in pen and with familiar smudges from the tears that stained the ink I was shocked at my discover y Twenty years ago my mother told me that she had destroyed the note because a counsellor

had advised her that holding on to it would prevent her recover y.

I believed her But she had kept it hidden from view but close to her hear t at the back of her Bible since 1986. I was shocked to find and hold this tragic note in my hands once again 30 years after my father had written his final words.

I’m still grieving for the loss of my mother but this bereavement feels different I’ve never lost a parent not by suicide before It’s a different type of grief I don't feel guilty.

I’m not angr y with my mother I’m not feeling guilty for feeling angr y I’m not tr ying to recall the warning signs I missed. I’m not blaming myself for not doing enough and for not being there that morning I’m not tor tured with the thought of the desperation and unhappiness that led to the death. I’m not confused and shocked and devastated

Unlike my mother’s passing; in the final hours of my father’s life he was in the depths of despair and alone There was no one there to hold his hand or mop his brow, to comfor t him or pray with him There was no one there to tell him how much we needed him, to beg him not to let go and to tell him just how much we loved him

I think of my father ever y day and the fact that he took his own life is a par t of me I don't want one more woman to experience what my mother went through. I don't want one more son to experience what I went through That’s why I am committed to the possibility of zero suicide I believe that ever y suicide is preventable up until the last moment of life .

• Tony Macaulay is chair of Contact. (Tony will give the opening address to Contact Suicide Prevention: What Works? conference on November 17 at Titanic Centre Belf ast).

‘’ There was no one there to tell him how much we needed him, to beg him not to let go and to tell him just how much we loved him

Malachi O’Hara, senior researcher for Green Party MLA Clare Bailey, says the rates of suicide ideation, suicide attempts and incidences of self-harm among the LGBT community are frightening

Suicide is ever yone ' s business. Or so they say In fact, suicide dispropor tionally affects cer tain communities, and in terms of the lesbian, gay, bisexual and/or transgender (LGBT) community, the rates of suicide ideation, suicide attempts and incidences of self-harm are frightening

It also dispropor tionally affects those living in the most socio-economically deprived communities

In a scoping exercise conducted by The Rainbow Project in 2013, funded by Comic Relief, found that 35.3 per cent of respondents had self-harmed, 25 7 per cent had attempted suicide , 46 9 per cent had experienced suicide ideation and 70.9 per cent had experienced depression

This builds on a body of local, national and international evidence suggesting much higher rates of poorer mental health and outcomes comparative to their heterosexual or cisgender peers

The LGBT community is not homogenous and different cohor ts within these communities experience this inequality differently As a broad understanding, the experiences of transgender people is worse than their gay, lesbian, or bisexual brothers and sisters; for women, they are dispropor tionally affected by experiences of self-harm and suicide ideation, and for men, it was in relation to attempts at suicide and experiences of depression

Just look at those figures. Ask your LGBT friends, colleagues and family about

these harsh, bald figures. This is their and my community’s experience

In my own personal experience , I struggled with a dark place in the early 2000s I returned home from England and was lucky to have the bosom of a suppor tive and nur turing family to help me learn to cope and be more resilient Suppor tive and caring family, friends and social networks are key to ensuring better mental health outcomes, par ticularly amongst younger people We must perform a cultural shift, and begin to treat mental health like our physical health. A facet of our health that it is OK to talk about it, and something that we all should work on to make better.

We all know the cyclical link between poorer mental health outcomes and substance use and misuse . And guess what? Yes, similar health inequalities exist in the use and misuse of substances amongst LGBT people They are almost three times as likely to have tried an illegal drug in their lifetime , are twice as likely to drink daily and smoke at a rate of almost double that of their heterosexual peers

Like other minority communities, this is an outcome of historic and still unaddressed inequality The World Health Organisation in 2014 said that effor ts to redress LGBT suicides must focus on addressing risk factors such as mental disorders, substance abuse , stigma, prejudice , and individual and institutional discrimination.

In Nor thern Ireland, our poorer

mental health outcomes are exacerbated by a range of factors We are the most endemically poorer par t of these islands We spend less per head than other jurisdictions on mental health and we are a society recovering from conflict. For LGBT communities, this is worsened by a continuing delay in tackling the inequalities that our communities face .

It’s impor tant to draw attention to the corridors of power and their capability to redress these issues

Public health, the statutor y and arm ’ slength bodies of Government and community/voluntar y sector are paying closer attention to the mental health and suicide inequalities experienced by LGBT people .

But it is up to Stormont to redress institutional discrimination Stormont has never brought forward any equality measures or equality legislation on the basis of sexual orientation or gender identity

Our new Programme for Government has high level outcomes of ‘increase respect for each other’ and ‘reduce health inequality’ Let us see it in action. Homophobia and transphobia kill. It’s time to root it out and that must star t at the hear t of decision-making

• Malachi O’Hara previously managed health services at The R ainbow Project and is a board member of Lighthouse, a suicide prevention charity in North Belf ast

I strugg led with a da rk place in the ea rly 2000s. I returned home from Eng la nd a nd was lucky to have the bosom of a supportive a nd nurturing f a mily to help me lea rn to cope a nd be more resilient

A smile of strength and a message of hope

For a young woman who has come through so much, 39-year-old Caitriona Cassidy looks remarkably well, upbeat and positive again about her life

As we sat in a room at the offices of the counselling ser vice Contact in Belfast, it’s difficult to imagine an earlier time in Caitriona’s life when she self-harmed on a regular basis and even tried to take her own life

She told me how she first came to use Contact’s Lifeline ser vice “I first used the 24/7 crisis line about four years ago I needed it to basically keep me alive , ” says Caitriona

“Whenever I became more stable and well I applied to be a member of the Contact ser vice user advocacy group, which was basically like feeding back into the Lifeline ser vice and using my own experience of what worked and what didn’t. I don’t use the helpline anymore . I don’t need to because I’m better and more stable and I’m not suicidal anymore

“But I was then I needed them to encourage me to get to appointments, to sometimes get up in the morning, to get myself to a hospital if I’d injured myself or taken overdoses – because I couldn’t do those sor ts of things for myself because I was too unwell

“Lifeline helped me to be able to do that They worked with my GP and my psychologist and my psychiatrist and sor t of brought things together. At the time , my mind felt split like a broken mirror Lifeline helped me to connect with different people in order for me to get better.”

How are you doing now, I asked

“I feel really good now I feel like I’ve gone through a period of properly growing up. I had just sor t of stumbled from day to day, not really paying attention to what was going on or how I was feeling or what I was thinking or who I was. ”

Were you not looking afterself?

“It was chaotic for years. All of my behaviours were really dangerous I’m now more moderate in how I do things and how I think and what behaviours I engage in I was diagnosed as having a borderline personality disorder That’s why I was so troubled for such a long time . ”

Caitriona comes from a family of seven She is the second eldest out of five children “I feel like I’ve always had problems I’ve always had difficulties with

life and being able to manage myself. It's really strange but I have ver y, ver y few memories of childhood at all

“After completing my A-Levels I went to university in England After getting a 2 1 in social sciences, I moved back to Ireland I star ted to worked as a classroom assistant for children with special needs It was amazing, I absolutely loved it.

“Work has always kept me stable – it’s always been positive for me My present employers have also been ver y suppor tive towards me

“I made my first attempt to kill myself when I was 19 It was ver y impulsive I’d been out, I’d drank a lot and I came home and thought that I wanted to die . My present medication is good for me because it reduces that impulsivity

“Life is really good now. I’ve learned I still need to talk and I still need to get better at it I have huge plans for the future . I want to do ever ything. Par t of my wish list is to visit Cuba and Jamaica

“I think it’s impor tant that people who are experiencing problems should talk about it Self-harm is a really strong addiction. Whenever you are in that pattern it just goes round and round in a cycle and it’s hard to break I think that led me on a path towards attempting suicide .

“People experiencing mental health problems should tr y to break the cycle They should phone Lifeline , the Samaritans or any other agency that’s going to help them.”

• Caitriona Cassidy is a social care professional and was recently appointed to Contact Board

In a remarkably frank interview, 39-year-old Caitriona Cassidy, above, ag reed to talk to VIEW about her past mental health dif ficulties, including self harm, suicide attempts and her long road to recovery

Life is really good now.

I’ ve lea rned I still need to talk a nd I still need to get better at it

Let’s not dodge the issue: Nor thern Ireland has an unacceptable level of young people dying by suicide Across the UK as a whole in 2014 there were 187 deaths by suicide of 15 to 19-year-olds, and in Nor thern Ireland we have the highest repor ted suicide rate across the UK for young people aged 10 to 14

Although the figures are small here , any young person taking their life is a tragedy for them and their families and we must all work to prevent as many cases as possible Our goal should be that no young person should ever feel that suicide is a solution to their problems

Last year, our ChildLine bases in the UK received calls from 350 young people in Nor thern Ireland who were worried about suicide On average , across the UK, the ser vice speaks to 53 children ever y day This is a concerning figure but at least it means that young people are choosing to seek the help our counsellors provide through text, telephone and online

There are many reasons for the rise in calls to ChildLine and turbulent home lives, abuse , school pressures, self-esteem issues and mental health problems all appear to be triggers for young people

The figures also pointed us to two impor tant issues: twice as many girls as boys are seeking help, and more calls are made at night.

These facts highlight the need to target young men and encourage them to speak out. We must challenge the stereotypical view that it is a weakness to

talk about feelings We also need to provide a full 24-hour ser vice for children so that they can find suppor t at all times For parents of young people reading this, we would encourage them to talk to their children about their feelings and discuss steps to promote good mental health These discussions can take place around the dinner table , on the school run or at any time – but it is vitally impor tant that we speak to our children and understand their feelings

Sometimes it can be difficult for adolescents and young people to open up to their families, par ticularly in this increasingly digital age where other people are available 24/7 for them to confide in But while the internet offers wonderful learning oppor tunities and many positives there are darker sides Cyber bullying and people who would seek to harm our children or persuade them to do things they shouldn’t are an ever-present threat So encouraging and giving young people routes to seek help and to talk about problems with people they know and trust is something we would surely all suppor t

As we are reissuing our suicide prevention strateg y at Stormont, all the agencies in Nor thern Ireland need to work together to tackle this terrible problem. There is no single or simple solution but collectively, working with young people and their families and using education and public health approaches, we must do whatever we can to change the current situation

It’s vital to talk to our children

Colin Reid, Policy and Public Affairs Manager at the NSPCC, says the goal should be that no young person should ever feel that suicide is a solution to their problems

‘’ There is no single or simple solution but collectively, working with young people and their families and using education and public health approaches, we must do whatever we can to change the current situation

Target should be zero deaths

Last year 318 people died by suicide This is the highest number of deaths ever recorded here . Health Minister Michelle O Neill recently said that the suicide figures in Nor thern Ireland are “stable” but perhaps that should be read as “consistently high”

My colleagues and I believe that suicide needs to be treated more urgently; the target for suicide deaths here should be zero and that ever yone in society can contribute to the eradication of suicide

We question why there is no public information campaign aimed at encouraging open and direct talk about suicide . Such a campaign could also help shatter many of the myths that surround suicide A par ticular myth is the widely held false belief that talking about suicide with someone in distress may “put the idea of suicide in their head”.

The current approach seems to be to raise awareness of mental health and illness, encourage help seeking, and then we may get a campaign aimed directly at suicide prevention

I believe this approach is flawed Suicide prevention is urgent and this “suicide must wait” approach may be costing us lives The other problem is that we need to differentiate between mental illness and suicide . Mental illness doesn’t kill people but suicide does

Communities should adopt the Suicide Safer Communities approach which provides a nine-element framework to enable and suppor t suicide prevention.

We know that many people in suicidal crisis pass the point of seeking help Many are unable to tell someone of their suicide thoughts or they may actively conceal their intentions This is why programmes like ASIST (Applied Suicide Inter vention Skills Training) and safeTALK (Suicide Aler tness for Ever yone) are so impor tant

People trained in ASIST can better identify people at risk of suicide and provide suppor t. Those trained in safeTALK can identify those with thoughts of suicide and refer them to an ASIST

trained caregiver or other experienced caregivers We need to train more people in these programmes in a systematic and targeted way Organisations, including GP practices, should have a small number of people trained in ASIST and the remainder trained in safeTALK

There has been a great improvement in the care provided to people bereaved by suicide here , par ticularly over the last three years. These people are at increased risk of suicide and are readily identifiable

They need timely, active and on-going care and suppor t It seems to me that families who initially decline help should be more actively engaged with at a later stage .

A consistent approach is required to ensure that all these families receive a follow-up visit from the police The visit could include a representative of the contracted post-inter vention ser vice provider

I also wonder how actively are we collecting data on the number of children who have lost a parent to suicide Timely appropriate care for these children will take the “legacy” of suicide from their lives and contribute long-term to preventing suicide

There is also a need to more clearly identify those sur vivors of suicide attempts. Their care needs are different from those who have engaged in self-harm People who have attempted suicide are at the apex of risk.

New approaches that have proved successful elsewhere should be piloted here These include the PISA model developed by Yvonne Bergmans and colleagues in Toronto, Canada; and the solution-focused work of Heather Fiske

The draft Protect Life 2 strateg y provides an ideal oppor tunity to adopt the ambition of zero suicides across Nor then Ireland If senior policy makers insist in “ more of the same ” approaches then communities themselves can adopt the suicide down to zero ambition until it becomes widely accepted that the potential for zero suicides is achievable

Pat McGreevy, a retired mental health services manager with the South Eastern Trust, believes that everyone in society can contribute to the eradication of suicide

‘’ We need to differentiate between mental illness and suicide . Mental illness doesn’t kill people but suicide does

Why

By now we will all know someone who has a mental health problem, self-harms or sadly died by suicide . This is devastating for ever yone concerned: family members, friends, schools and the wider community All we are left with is the question: why?

Thankfully, many more schools are now recognising mental health, suicide and self-harm as a real life issue which is affecting our young people at an alarming rate However, things don't aways move as fast as one would like and work needs to continue to encourage more schools to open their doors to allow this life-saving work to proceed.

Young people today live in a world which is fast and furious With more pressures than ever before put upon them, many are coping with difficult life issues which present a challenge for schools who cannot always provide the appropriate training or suppor t

Positive mental health and emotional well-being for all young people of all ages is an impor tant foundation for learning and educational achievement.

Research in this field demonstrates that a person ’ s ability to perceive , identify and manage emotion is the basis for being successful

I personally believe that with the advent of social media and ever busier lives for our young people , we are in danger of losing the ar t of face to face communication Asking a friend face to face: “how are you keeping?” “What's going on?” “How are you?” is often all that is required Sadly, many young people have expressed suicidal thoughts in the year before they died – it may have been verbally or through behavioural change that had gone unnoticed.

Therefore , the more schools we can access to deliver training which will encourage students and teachers to feel

confident and willing to explore possible signs of suicide risk, then the more suppor t, guidance and help will be on offer that could potentially save lives.

The figures for self-harm and suicide in 2015 are alarmingly high Positive mental health education within schools from an early age is essential and should provide children and young people with vital life skills, a key protective factor for self-harm and suicide which include critical thinking, stress management, conflict resolution, problem-solving, and coping skills Training that strengthens these skills can help young people as they face new challenges, such as employment, relationships, economic stress, divorce and physical illness

Education and awareness need to be raised within schools and communities as a priority and to a broad range of people in order to equip them with the necessar y skills and confidence to reach out to someone who needs help Suicide can affect any one of us and it is our responsibility to find ways to make suicidesafer schools and communities

The aim of MindSkills Training & Coaching is to highlight issues such as suicide , self-harm, and promote positive mental health, encouraging people in the local community, schools and business to break down the barriers and stigma which stop people seeking help

I would like to end this ar ticle with a quote from former tennis player Andre Agassi: “This is the only perfection there is, the perfection of helping others This is the only thing we can do that has any lasting meaning This is why we ’ re here To make each other feel safe ”

• Philip McTaggart is managing director of MindSkills Training & Coaching which delivers positive mental health training –www.mind-skills.net

emotional support is vital

Philip McTaggart, who lost his son Philip to suicide in 2003, believes it’s vital that more mental health awareness training is provided for young people in our schools

‘’

Thankfully, many more schools are recognising mental health, suicide and self-harm as a real life issue affecting our young people at an alarming rate

Concern over elderly suicide rate

Dr. Nikolaos Antonakakis, Associate Professor at Webster Vienna University, urges policy makers to put European citizens' health before wealth as a matter of some urgency

When Nobel Prize-winning economist Joseph Stiglitz called Europe’s aggressive austerity policies “ a mutual suicide pact”, he was speaking metaphorically But his 2012 prediction turned out to be literal, too

Since the global financial crisis of 2008 many Eurozone peripher y countries experienced increased budget deficits and debts that raised fears about a chain reaction of sovereign defaults, and possible contagion to other core Eurozone countries, that led to a crisis of confidence and a widening of bond yield spreads

These developments have ultimately initiated an (ongoing) European sovereign debt crisis in 2009 that has resulted in large financial inter ventions in the Eurozone peripheral countries by individual governments and the ‘Troika’ (consisting of the European Commission (EC), the European Central Bank (ECB) and the International Monetar y Fund (IMF). Such inter ventions occurred in an attempt to aver t potential bankruptcies of highly indebted countries in the Eurozone peripher y, potential contagion and ultimately the collapse of the Eurozone itself

Politicians and policy makers have talked endlessly about the seismic economic and social impacts of the recent financial crisis However, many continue to ignore its disastrous effects on human health and have even exacerbated them, by adopting harsh fiscal austerity measures and cutting key social programs at a time when constituents need them most. Many countries have turned their recessions into veritable epidemics, ruining or extinguishing thousands of lives in a misguided attempt to balance budgets and shore up financial markets.

Increasingly, the pursuit of fiscal consolidation was recognized by an IMF repor t in 2013 as ineffective and prolonging the economic crisis unnecessarily In par ticular, back in 2010, the IMF predicted that the proposed austerity policies would reduce gross domestic product (GDP) only by 5.5 per cent based on its estimates of a fiscal mul-

tiplier of 0 5 By 2013, the Greek economy had contracted by 17 per cent, and the negative impacts of austerity on GDP in other European countries were also higher than expected, due to the wrong IMF’s estimates of the fiscal multiplier, concluding that the actual value was somewhere between 0 9 and 1 7

More impor tantly, the effects of fiscal austerity on debt ravaged Eurozone peripheral countries included a dramatic rise in the number of elderly men taking their own lives. According to two research co-authored studies of mine with Dr Alan Collins (University of Por tsmouth) that were published in 2014 and 2015 in the highly prestigious scientific journal Social and Science Medicine , we found that a one per cent reduction in government spending is associated with a 1 38 per cent, 2 42 per cent and 3.32 per cent. increase in the shor t, medium and long-run, respectively, of male suicides rates in the 65-89 age group in the Eurozone peripher y Specifically, 4,555 male suicides between the ages of 65 and 89 are predicted to have occurred in the aforementioned five Eurozone peripheral countries between 2009 and 2014

Yet we also found that sound alternative/complementar y policies could instead help improve economies and protect public health at the same time . We showed that the negative effects of economic downturns and fiscal austerity could be mitigated by the adoption of re-distributive policies (e g higher unemployment benefits) and by investing in some specific elements of stronger social protection in the Eurozone peripher y (e g targeting and prevention of the most deprived par ts of the population) These findings have substantial implications for policy makers in the domain of economics and health across Europe Economic and financial issues have been dominating policy making in the Eurozone , while health and inequalities in health remained relatively low key

Given that economic and social policy decisions have profound effects for (mental) health and its fair distribution, health equity should perhaps be considered an impor tant measure of the effectiveness of social and economic policy making, in addition to wealth equity

‘’

The effects of fiscal austerity on debt ravaged Eurozone peripheral countries (Greece , Ireland, Italy, Por tugal and Spain), included a dramatic rise in the number of elderly men taking their own lives