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Mental health care concerns - in Hereford Times

By Rebecca Cain

01432845883       17 March 2016 p6           Twitter @HTNewsroom

A man who took his own life has led a coroner to question the care he received from mental health services prior to his death.

The Hereford inquest last week heard that Mark Brownlie was found hanged at his home in Cedar Close, Moreton-on-Lugg.   Neighbours had raised the alarm after he had not been seen for a few weeks before police attended the 45-year-old's address on October 20.

County coroner, Mark Bricknell, told Dr Barnaby Major, from the 2gether NHS Foundation Trust, that he was concerned about the level of intervention from mental health services.

Mr Bricknell questioned why some paperwork classed Mr Brownlie as a moderate risk of deliberate self harm and/ or suicide, yet Dr Major said he was at a low risk.

Dr Major told the inquest there was a formal process of risk assessment which put him in a moderate risk category but that mental health staff will override this process based on their interpretation and how well they know the patient.

He said: "Medicine is a science but an art as well. It is about following your gut feeling and doing what you think is right for the patient at that moment."

Mr Bricknell asked whether Dr Major became concerned when Mr Brownlie did not attend appointments in the months leading up to his death but Dr Major said this was reflective of his personality disorder, and he would often not turn up for appointments.

He said they had to be careful to strike a balance and added: "He didn't want people coming around and knocking on his door."

Dr Major said the care plan, which said Mr Brown-lie should have two members of staff visiting him at

home if he did not turn up for appointments, was out of date and had been made in 2012. They had not had time to write a new one.

He added: "It is a reflection on modern NHS services. Often there is a gap between policy and process. Often people do things because they are going to be scrutinised. They are going to be leaning towards performance targets."

Dr Major said he was genuinely shocked when he discovered he had died and said he had clearly got it wrong.

Mr Bricknell recorded that Mr Brownlie took his own life. He said: "He was a troubled man with a complicated history of mental health issues.

"He failed to attend appointments with medical professionals but not withstanding this it is disappointing contact was not made to a greater extent in the month prior to his death. The difficulty of managing patients in such circumstances must, however, be acknowledged."

End of newspaper report.

The website author, in the context of his wife's inadequate treatment by 2gether, withdrew from contact with the organisation in February 2016.  The one-line care plan for twelve months amounted to - keep on taking the tablets.

Another factor was being told that using email to communicate with 2gether is unhealthy and it should be discontinued.  The fact is at least one psychiatric nurse who operates this policy turned up to an appointment which had been cancelled by the author by email several days before.  

Had Mark Brownlie used email to warn 2gether of his intentions several days in advance, 2gether would not have found out until it was over.


On page 28 of the same newspaper, there is a brief announcement of a question-time event of relevance on Tuesday 22 March at Hereford Sixth Form College.  This website looks forward to reporting the event as published.

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